Pharmaceutical compositions and methods of using the same

ABSTRACT

Novel pharmaceutical compositions including cocaine hydrochloride and methods of treating patients using those pharmaceutical compositions are described.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation application claiming priority under 35 U.S.C. § 120 to U.S. patent application Ser. No. 16/246,241, filed Jan. 11, 2019, entitled PHARMACEUTICAL COMPOSITIONS AND METHODS OF USING THE SAME, which application is a continuation application claiming priority under 35 U.S.C. § 120 to U.S. patent application Ser. No. 15/434,014, filed Feb. 15, 2017, entitled PHARMACEUTICAL COMPOSITIONS AND METHODS OF USING THE SAME, which issued as U.S. Pat. No. 10,231,961, on Mar. 19, 2019, which application claims priority under 35 U.S.C. § 120 as a continuation-in-part of U.S. patent application Ser. No. 15/427,011, filed Feb. 7, 2017, entitled PHARMACEUTICAL COMPOSITIONS AND METHODS OF USING THE SAME, which issued as U.S. Pat. No. 10,149,843, on Dec. 11, 2018. The entire disclosures of such applications are hereby incorporated herein by reference in their entireties.

FIELD OF THE TECHNOLOGY

The present disclosure relates to novel pharmaceutical compositions and methods of treating subjects using those compositions.

DESCRIPTION OF THE BACKGROUND OF THE TECHNOLOGY

Anesthesia is a partial or complete loss of sensation or feeling induced by the administration of various substances. Types of anesthesia are usually classified in one of three main groups: general anesthesia, local anesthesia, and spinal anesthesia. General anesthetics act primarily on the brain, rendering people both insensible to pain and unconscious. Local anesthetics affect only part of the body, and the patient remains conscious. Certain local anesthetics are administered by applying a gel or cream onto the skin or mucosa, while others are injected. When local anesthetics are applied directly to the skin or mucosa they are also referred to as topical anesthetics. Topical anesthetics are absorbed through the skin or mucosa and interact with nerve endings in the dermis. Once topical anesthetics are absorbed, they cause a depolarization of sensory nerves within the outer dermis, temporarily deactivating the sensory nerves. While the anesthetic effect is present, the deactivated sensory nerves do not transmit impulses to the brain, and painful sensations within the anesthetized body region are temporarily decreased or eliminated.

Topical anesthetics are routinely used to provide anesthesia for the skin, eyes, ears, nasal mucosa, oral mucosa, and bronchotracheal area. Topical anesthetics avoid the pain and tissue distortion associated with invasive, injected forms of anesthesia.

Topical nasal anesthesia is used for the management of both routine and emergency procedures, including nasal examination, management of nasal and facial trauma, out-patient and in-patient sino-nasal procedures, and management of facial and nasal abscesses.

Two classes of topical nasal anesthetics are available: amides (e.g., lidocaine) and esters (e.g., benzocaine, tetracaine, cocaine). The mechanism of action of both amides and esters are similar; each prevents conduction in nerve fibers by reversibly blocking sodium channels and preventing the transient rise in sodium conductance necessary for generation of an action potential. The primary mechanism of local anesthetics, in general, is to interfere with Na⁺ channel activity, thereby preventing depolarization of target cells and reducing or blocking nerve conduction. Sodium channels are responsible for controlling Na⁺ ion conductance in excitable cells such as neurons and myocardial cells.

Depending on the indication, topical nasal anesthesia may be obtained by the use of topical sprays, cotton swabs, nasal injections, regional nerve blocks, or with a combination of these approaches.

Anesthetics are sometimes combined with a vasoconstrictor to reduce the risk of anesthetic toxicity. The vasoconstrictor reduces systemic absorption of the anesthetic and increases the anesthetic's local tissue retention time. Increased retention time allows the anesthetic to metabolize more slowly, until local vasoconstriction is reversed. Oxymetazoline, epinephrine, or another adrenergic agonist is sometimes used in combination with a topical nasal anesthetic to increase vasoconstriction and to prolong the anesthetic effect by decreasing the rate of systemic absorption.

Epinephrine is commonly used in combination with an anesthetic for intravenous administration in concentrations ranging from 0.0000001% to 0.0001% weight by volume. However, because epinephrine is one of the most powerful alpha 1 agonists, significant cardiovascular side effects may occur, with an increased risk of hypertension, stroke, arrhythmia, or infarction, particularly in individuals with a history of cardiovascular disease.

Cocaine is a naturally-derived compound with anesthetic properties, and it can also be made synthetically. Cocaine prevents conduction in nerve fibers by reversibly blocking sodium channels and preventing the transient rise in sodium conductance necessary for generation of an action potential. Cocaine passes into Na⁺ channels and binds to the inside of the cell membrane, inhibiting further conduction of Na⁺ ions through the membrane of electrically active cells, such as nerve cells. Thus, for example, when cocaine is topically applied to a nasal mucous membrane, it is absorbed into the underlying tissue and prevents generation of nerve impulses in electrically active cells, producing a desensitizing effect in the affected cells and tissues of the nasal cavity. The onset and duration of the anesthetic effect of cocaine is dependent on the administered dose and the manner of administration.

Cocaine has no anesthetic effect when applied to intact skin, but is readily absorbed from denuded areas and through mucous membranes. Cocaine has properties that can make it useful as an active agent in topical anesthetic compositions administered prior to diagnostic or surgical procedures performed on highly vascularized regions of a human body (e.g., the nose, throat, larynx, and lower respiratory passages). Cocaine has vasoconstrictor activity which can reduce operative bleeding, and it exhibits both a short time to the onset of localized anesthetic effect and a short duration of action.

Many anesthetic pharmaceutical compositions have poor stability, and hence it may be necessary to prepare the compositions just prior to use. This can be inconvenient or impossible depending on the application and the available facilities. Further, certain topical anesthetics are administered using a tape-shaped medicament, which is unsuited for anesthetizing certain body mucosa (e.g., nasal passages, ear canals, throat, mouth, and eyes).

Accordingly, there is a need for a local anesthetic composition that exhibits advantageous stability and produces vasoconstriction during local anesthesia without systemic negative side effects that can be produced by epinephrine.

SUMMARY

It is understood that the inventions disclosed and described in this specification are not limited to the embodiments described in this Summary.

A non-limiting aspect of the present disclosure is directed to a ready to use pharmaceutical composition comprising about 4% cocaine hydrochloride, by weight, and a preservative in an aqueous solution, wherein a pH of the pharmaceutical composition is 2 to 4. The pharmaceutical composition exhibits advantageous stability, and the cocaine hydrochloride concentration in the pharmaceutical composition remains greater than about 3.4%, by weight, after the composition has been stored for 12 months at a temperature ranging from 23° C. to 27° C. and a relative humidity ranging from 55% to 65%.

Another non-limiting aspect of the present disclosure is directed to a ready to use pharmaceutical composition comprising about 4% cocaine hydrochloride, by weight, and a preservative in an aqueous solution, wherein a pH of the pharmaceutical composition is 2 to 4, and wherein the cocaine hydrochloride concentration in the pharmaceutical composition remains at greater than about 3.4%, by weight, after the composition has been stored for 6 months at a temperature ranging from 28° C. to 32° C. and a relative humidity ranging from 60% to 70%.

Yet another non-limiting aspect of the present disclosure is directed to a ready to use pharmaceutical composition comprising about 4% cocaine hydrochloride, by weight, and a preservative in an aqueous solution, and wherein the cocaine hydrochloride concentration in the pharmaceutical composition remains greater than about 3.4%, by weight, after the composition has been stored for 1 month at a temperature ranging from 38° C. to 42° C. and a relative humidity ranging from 70% to 80%.

An additional non-limiting aspect according to the present disclosure is directed to a storage stable pharmaceutical composition comprising about 4% cocaine hydrochloride, by weight, and a preservative in an aqueous solution, wherein a pH of the pharmaceutical composition is 2 to 4, and wherein the pharmaceutical composition comprises no more than 7% of total impurities, by weight, after the composition has been stored for 20 months at a temperature ranging from 23° C. to 27° C. and a relative humidity ranging from 55% to 65%.

A further non-limiting aspect according to the present disclosure is directed to a storage stable pharmaceutical composition comprising about 4% cocaine hydrochloride, by weight, and a preservative in an aqueous solution, wherein a pH of the pharmaceutical composition is 2 to 4, and wherein the pharmaceutical composition comprises no more than 8% of total impurities, by weight, after the composition has been stored for 12 months at a temperature ranging from 28° C. to 32° C. and a relative humidity ranging from 60% to 70%.

Yet a further non-limiting aspect according to the present disclosure is directed to a storage stable pharmaceutical composition comprising about 4% cocaine hydrochloride, by weight, and a preservative in an aqueous solution, wherein a pH of the pharmaceutical composition is 2 to 4, and wherein the pharmaceutical composition comprises no more than 10% of total impurities, by weight, after the composition has been stored for 6 months at a temperature ranging from 38° C. to 42° C. and a relative humidity ranging from 70% to 80%.

An additional non-limiting aspect according to the present disclosure is directed to a pharmaceutical composition for reducing sensation in a body region of a subject, wherein the pharmaceutical composition comprises about 4% cocaine hydrochloride, by weight, and a preservative, in an aqueous solution, and wherein the pharmaceutical composition results in a cocaine AUC_(inf) in the subject ranging from 30.8 ng*h/mL to 79.0 ng*h/mL following a topical application of the pharmaceutical composition to the subject for about 20 minutes.

Another non-limiting aspect according to the present disclosure is directed to a pharmaceutical composition for reducing sensation in a body region of a subject, the pharmaceutical composition comprising about 4% cocaine hydrochloride, by weight, and a preservative, in an aqueous solution, and wherein the pharmaceutical composition results in a cocaine C_(max) ranging from 19.7 ng/mL to 54.3 ng/mL in the subject following a topical application of the pharmaceutical composition to the subject for about 20 minutes.

An additional non-limiting aspect according to the present disclosure is directed to a pharmaceutical composition for reducing sensation in a body region of a subject, wherein the pharmaceutical composition comprises about 4% cocaine hydrochloride, by weight, and a preservative, in an aqueous solution, and wherein the pharmaceutical composition results in a cocaine T_(max) of 0.09 h to 0.77 h in the subject following a topical application of the pharmaceutical composition to the subject for about 20 minutes.

One further non-limiting aspect according to the present disclosure is directed to a pharmaceutical composition for reducing sensation in a body region of a subject, the pharmaceutical composition comprising about 4% cocaine hydrochloride, by weight, and a preservative, in an aqueous solution, and wherein the pharmaceutical composition results in an absorptivity factor for cocaine in the in subject ranging from 0.640 h⁻¹ to 0.687 h⁻¹ following a topical application of the pharmaceutical composition to the subject for about 20 minutes.

Yet a further non-limiting aspect according to the present disclosure is directed to a method of administering a topical anesthetic solution comprising cocaine hydrochloride to a subject to provide a reduction in sensation in a body region of the subject. The method comprises soaking absorbent articles with a solution comprising about 4%, by weight, cocaine hydrochloride, and contacting the absorbent articles with a nasal mucous membrane of the subject for at least about 20 minutes, wherein the method achieves a cocaine AUC_(inf) in the subject ranging from 30.8 ng*h/mL to 79.0 ng*h/mL.

Another aspect of the present disclosure is directed to a method of administering a topical anesthetic solution comprising cocaine hydrochloride to a subject to reduce sensation in a body region of the subject, wherein the method comprises soaking absorbent articles with a solution comprising about 4%, by weight, cocaine hydrochloride, and contacting the absorbent articles with a nasal mucous membrane of the subject for at least about 20 minutes, wherein the method achieves a cocaine T_(max) in the subject ranging from 0.09 h to 0.77 h.

Yet another non-limiting aspect of the present disclosure is directed to a method of administering a topical anesthetic solution comprising cocaine hydrochloride to a subject to reduce sensation in a body region of the subject, wherein the method comprises soaking absorbent articles with a solution comprising about 4%, by weight, cocaine hydrochloride and contacting the absorbent articles with a nasal mucous membrane of the subject for at least about 20 minutes, wherein the method achieves a cocaine C_(max) in the subject ranging from 19.7 ng/mL to 54.3 ng/mL.

One additional non-limiting aspect of the present disclosure is directed to a method of administering a topical anesthetic solution comprising cocaine hydrochloride to a subject, the method comprising soaking absorbent articles with a solution comprising about 4%, by weight, cocaine hydrochloride, and contacting the absorbent articles with a nasal mucous membrane of the subject for at least about 20 minutes, wherein the method achieves an absorptivity factor for cocaine in the subject ranging from 0.640 h⁻¹ to 0.687 h⁻¹.

Another non-limiting aspect of the present disclosure is directed to a method of administering a topical anesthetic solution comprising cocaine hydrochloride to a subject to reduce sensation in a body region of the subject, the method comprising soaking absorbent articles with a solution comprising about 4%, by weight, cocaine hydrochloride, and contacting the absorbent articles with a nasal mucous membrane of the subject for at least about 20 minutes, wherein a urinary recovery of cocaine hydrochloride from the subject ranges from 38.9 μg to 289.5 μg over a period of 32 hours from the time of administration of the solution.

Another non-limiting aspect of the present disclosure is directed to a method of administering a topical anesthetic solution comprising cocaine hydrochloride to a subject to reduce sensation in a body region of the subject, wherein the method comprises soaking absorbent articles with a solution comprising about 4%, by weight, cocaine hydrochloride, and contacting the absorbent articles with a nasal mucous membrane of the subject for at least about 20 minutes, wherein the method achieves an ecgonine methyl ester C_(max) in the subject ranging from 1.8 ng/mL to 13.2 ng/mL.

Yet another non-limiting aspect of the present disclosure is directed to a method of administering a topical anesthetic solution comprising cocaine hydrochloride to a subject to reduce sensation in a body region of the subject, wherein the method comprises soaking absorbent articles with a solution comprising about 4%, by weight, cocaine hydrochloride, and contacting the absorbent articles with a nasal mucous membrane of the subject for at least about 20 minutes, wherein the method achieves a benzoylecgonine C_(max) in the subject ranging from 8.4 ng/mL to 103 ng/mL

In certain non-limiting embodiments of the present disclosure, a method for inducing local anesthesia in a subject prior to performing a diagnostic, surgical, or post-operative procedure on or through the mucous membrane of the nasal cavities of a subject comprises soaking a cottonoid pledget with 1 mL of a colored aqueous solution comprising or consisting essentially of, by weight, about 4% cocaine hydrochloride, about 0.1% sodium benzoate, about 0.125% citric acid, optionally one or more colorants, and water, and contacting the soaked cottonoid pledget with the mucous membrane of the subject for at least about 20 minutes.

In another non-limiting aspect of the present disclosure, a method of effectively anesthetizing a body region of a subject comprises immersing at least one absorbent article in an aqueous pharmaceutical composition comprising, by weight, about 3.6% to about 4.4% cocaine hydrochloride, about 0.07% to about 0.20% sodium benzoate, and about 0.125% citric acid, wherein the aqueous pharmaceutical composition has a pH between 2 and 4. The method further includes contacting the absorbent article and the aqueous pharmaceutical composition absorbed therein with a mucous membrane of the subject for a time period sufficient to reduce sensation in the body region proximate the mucous membrane. In certain non-limiting embodiments, the time period is sufficient to achieve a visual numeric rating score of 0 in the body region proximate the mucous membrane upon von Frey filament testing.

Certain other non-limiting aspects of the present disclosure are directed to a method of effectively anesthetizing a body region of a subject prior to performing a medical procedure on the subject. The method comprises immersing at least one absorbent article in an aqueous pharmaceutical composition comprising, by weight, about 3.6% to about 4.4% cocaine hydrochloride, about 0.07% to about 0.20% sodium benzoate, and about 0.125% citric acid, wherein the aqueous pharmaceutical composition has a pH between 2 and 4. The method further includes contacting the at least one absorbent article and the aqueous pharmaceutical composition absorbed therein with a mucous membrane of the subject for a time period, and obtaining a reduction in sensation in the body region proximate to the mucous membrane. In certain non-limiting embodiments, the reduction in sensation results in a visual numeric rating score of 0 upon von Frey filament testing the body region.

Another non-limiting aspect of the present disclosure is directed to a method of effectively anesthetizing a body region of a hepatically impaired subject. The method comprises immersing at least one absorbent article in an aqueous pharmaceutical composition comprising, by weight, about 3.6% to about 4.4% cocaine hydrochloride, about 0.07% to about 0.20% sodium benzoate, and about 0.125% citric acid, wherein the aqueous pharmaceutical composition has a pH between 2 and 4. The method further includes contacting the at least one absorbent article and the aqueous pharmaceutical composition absorbed therein with a mucous membrane of the subject for a time period sufficient to reduce sensation in a body region proximate the mucous membrane. The reduction in sensation results in a visual numeric rating score of 0 upon von Frey filament testing the body region. The method is not repeated on the hepatically impaired subject within 24 hours.

Another non-limiting aspect of the present disclosure is directed to a method of effectively anesthetizing a body region of a renally impaired subject. The method comprises immersing at least one absorbent article in an aqueous pharmaceutical composition comprising, by weight, about 3.6% to about 4.4% cocaine hydrochloride, about 0.07% to 0.20% sodium benzoate, and 0.125% citric acid, wherein the aqueous pharmaceutical composition has a pH between 2 and 4. The method further includes contacting the at least one absorbent article and the aqueous pharmaceutical composition absorbed therein with a mucous membrane of the subject for a time period sufficient to reduce sensation in a body region proximate the mucous membrane. The reduction in sensation results in a visual numeric rating score of 0 upon von Frey filament testing the body region.

BRIEF DESCRIPTION OF THE DRAWINGS

Various features and characteristics of non-limiting and non-exhaustive embodiments disclosed and described in this specification may be better understood by reference to the accompanying figures, in which:

FIG. 1 is a schematic representation showing certain metabolic pathways of cocaine in humans.

FIG. 2 is a plot of plasma concentration of cocaine as a function of time following administration of an intranasal dose of a pharmaceutical composition including cocaine hydrochloride in a concentration of 40 mg/mL.

FIG. 3 is a plot of urinary recovery of cocaine, benzoylecgonine (BE), and ecgonine methylester (EME) as a function of time following administration of an intranasal dose of a pharmaceutical composition including cocaine hydrochloride in a concentration of 40 mg/mL.

FIG. 4 is box and dot plot of the natural log of cocaine AUC_(last) by subject gender following administration of an intranasal dose of a pharmaceutical composition including cocaine hydrochloride in a concentration of 40 mg/mL.

FIG. 5 is a plot of the natural log of cocaine AUC_(last) as a function of subject age following administration of an intranasal dose of a pharmaceutical composition including cocaine hydrochloride in a concentration of 40 mg/mL.

FIG. 6 is a plot of the natural log of cocaine AUC_(last) as a function of subject body weight following administration of an intranasal dose of a pharmaceutical composition including cocaine hydrochloride in a concentration of 40 mg/mL.

FIG. 7 is a plot of the natural log of cocaine AUC_(last) as a function of subject body mass index (BMI) following administration of an intranasal dose of a pharmaceutical composition including cocaine hydrochloride in a concentration of 40 mg/mL.

FIG. 8 is a linear plot of mean plasma cocaine concentration (including standard deviations) as a function of time following administration of an intranasal dose of a pharmaceutical composition including cocaine hydrochloride in a concentration of 40 mg/mL to subjects with normal renal function and subjects with severe renal impairment.

FIG. 9 is a logarithmic plot of plasma cocaine concentration as a function of time following administration of an intranasal dose of a pharmaceutical composition including cocaine hydrochloride in a concentration of 40 mg/mL to subjects with normal renal function and subjects with severe renal impairment.

FIG. 10 is a linear plot of mean cocaine plasma concentration (including standard deviations) as a function of time following administration of an intranasal dose of a pharmaceutical composition including cocaine hydrochloride in a concentration of 40 mg/mL to subjects with normal hepatic function and subjects with hepatic impairment.

FIG. 11 is a logarithmic plot of plasma cocaine concentration as a function of time following administration of an intranasal dose of a pharmaceutical composition including cocaine hydrochloride in a concentration of 40 mg/mL to subjects with normal hepatic function and subjects with hepatic impairment.

FIG. 12 shows a visual numeric rating scale for assessment of pain as used to determine analgesic success.

FIGS. 13A and 13B, respectively, are side and sectional views of 0.5 oz. amber glass container used to contain a pharmaceutical composition, as described herein.

FIGS. 14A-14C are views of a container closure system that can be used in conjunction with the container shown in FIGS. 13A and 13B, wherein FIG. 14A is an exterior elevational view of a ribbed, threaded closure cap, FIG. 14B is a side sectional view of the cap shown in FIG. 14A, and FIG. 14C is an exploded sectional view of the cap shown in FIG. 14B.

FIG. 15 is a plot of the cocaine hydrochloride assay percentage as a function of time for a pharmaceutical composition (batch lot S35900113) stored in an upright container over a 20-month period at 25° C.±2° C. and 60%±5% relative humidity, thereby providing an assessment of the shelf life stability of the pharmaceutical composition.

FIG. 16 is a plot of the cocaine hydrochloride assay percentage as a function of time for a pharmaceutical composition (batch lot S35900113) stored in an inverted container over a 20-month period at 25° C.±2° C. and 60%±5% relative humidity, thereby providing an assessment of the shelf life stability of the pharmaceutical composition.

FIG. 17 is a plot of the cocaine hydrochloride assay percentage as a function of time for a pharmaceutical composition (batch lot S35900113) stored in an upright container over a 6-month period at 40° C.±2° C. and 75%±5% relative humidity, thereby providing an assessment of the shelf life stability of the pharmaceutical composition.

FIG. 18 is a plot of the cocaine hydrochloride assay percentage as a function of time for a pharmaceutical composition (batch lot S35900113) stored in an inverted container over a 6-month period at 40° C.±2° C. and 75%±5% relative humidity, thereby providing an assessment of the shelf life stability of the pharmaceutical composition.

FIG. 19 is a plot of the cocaine hydrochloride assay percentage as a function of time for a pharmaceutical composition (batch lot S35900113) stored in an upright container over a 12-month period at 30° C.±2° C. and 65%±5% relative humidity, thereby providing an assessment of the shelf life stability of the pharmaceutical composition.

FIG. 20 is a plot of the cocaine hydrochloride assay percentage as a function of time for a pharmaceutical composition (batch lot S35900113) stored in an inverted container over a 12-month period at 30° C.±2° C. and 65%±5% relative humidity, thereby providing an assessment of the shelf life stability of the pharmaceutical composition.

FIG. 21 is a plot of the cocaine hydrochloride assay percentage as a function of time for a pharmaceutical composition (batch lot C35900114A) stored in an upright container over a 24-month period at 5° C.±2° C., thereby providing an assessment of the shelf life stability of the pharmaceutical composition.

FIG. 22 is a plot of the cocaine hydrochloride assay percentage as a function of time for a pharmaceutical composition (batch lot C35900114A) stored in an inverted container over a 24-month period at 5° C.±2° C., thereby providing an assessment of the shelf life stability of the pharmaceutical composition.

The reader will appreciate the foregoing details, as well as others, upon considering the following detailed description of various non-limiting and non-exhaustive embodiments according to the present disclosure.

DETAILED DESCRIPTION

Various embodiments are described and illustrated in this specification to provide an overall understanding of the disclosed compositions and methods. It is understood that the various embodiments described and illustrated in this specification are non-limiting and non-exhaustive. Thus, the present invention is not limited by the description of the various non-limiting and non-exhaustive embodiments disclosed in this specification. Rather, the invention is defined solely by the claims. Certain features and characteristics illustrated and/or described in connection with various embodiments may be combined with the features and characteristics of other embodiments. Such modifications and variations are intended to be included within the scope of this specification. As such, the claims may be amended to recite any features or characteristics expressly or inherently described in, or otherwise expressly or inherently supported by, this specification. Further, Applicant reserves the right to amend the claims to affirmatively disclaim features or characteristics that may be found present in the prior art. The various embodiments disclosed and described in this specification can comprise, consist of, or consist essentially of the features and characteristics as variously described herein.

All percentages and ratios provided herein for a composition are weight percentages based on the total weight of the composition, unless otherwise indicated.

Any patent, publication, or other disclosure material that is said to be incorporated, in whole or in part, by reference herein is incorporated herein only to the extent that the incorporated material does not conflict with existing definitions, statements, or other disclosure material set forth in this disclosure. As such, and to the extent necessary, the disclosure as set forth herein supersedes any conflicting material incorporated herein by reference. Any material, or portion thereof, that is said to be incorporated by reference herein, but which conflicts with existing definitions, statements, or other disclosure material set forth herein is only incorporated to the extent that no conflict arises between that incorporated material and the existing disclosure material.

Any numerical ranges recited in this specification are intended to include all sub-ranges of the same numerical precision subsumed within the recited range. For example, a range of “1.0 to 10.0” is intended to include all sub-ranges between (and including) the recited minimum value of 1.0 and the recited maximum value of 10.0, that is, having a minimum value equal to or greater than 1.0 and a maximum value equal to or less than 10.0, such as, for example, 2.4 to 7.6. Any maximum numerical limitation recited in this specification is intended to include all lower numerical limitations subsumed therein and any minimum numerical limitation recited in this specification is intended to include all higher numerical limitations subsumed therein. Accordingly, Applicant reserves the right to amend this specification, including the claims, to expressly recite any sub-range subsumed within the ranges expressly recited herein.

The terms “mucosa” and “mucous membrane” as used herein refer to any naturally moist anatomical membrane or surface of a mammal, such as, for example, nasal, oral, aural, buccal, vaginal, rectal, and ophthalmic surfaces.

The terms “topical” and “topically” as used herein are used in a conventional sense, referring to direct contact with an anatomical site or surface area on a mammal, including, for example, skin and mucosa.

The term “C_(max)” as used herein refers to the maximum (i.e., peak) serum concentration.

The term “C_(last)” as used herein refers to the last observed quantifiable concentration.

The term “MRT” as used herein refers to the mean residence time, or the average amount of time that a single molecule of drug stays in the body.

The term “CL/F” as used herein refers to the apparent total clearance of the drug from plasma.

The term “Vd/F” as used herein refers to the apparent volume of distribution after non-intravenous administration.

The term “AUC” as used herein refers to the integral of the concentration-time curve.

The term “AUC_(last)” and “AUC_(0→t)” as used herein refer to the area under a plasma concentration versus time curve from time 0 to the time of the last measured concentration of drug within the plasma.

The terms “AUC_(inf)” and “AUC_(0→∞)” as used herein refer to the area under a plasma concentration versus time curve from time 0 to infinity.

The term “T_(max)” as used herein refers to the time after administration of a drug when the maximum plasma concentration is reached.

The term “t_(1/2)” as used herein refers to the half-life of an administered drug.

The term “T_(last)” as used herein refers to the time of the last observed quantifiable concentration of drug.

The term “% EXTRAP” as used herein refers to the percentage of area under the concentration-time curve (AUC) extrapolated after the last observed quantifiable concentration of drug (T_(last)).

The term “absorptivity factor” as used herein refers to the maximum concentration of drug absorbed into the blood plasma (C_(max)) divided by the area under the drug concentration-time curve from time 0 to infinity (AUC_(inf)).

The term “renal clearance” as used herein refers to the volume of plasma cleared of drug by the kidney per unit time.

The terms “subject” and “patient” are used interchangeably herein, and it is intended that both refer to a recipient on whom a method is conducted according to the present disclosure or another method, as the case may be.

The term “volume of distribution” as used herein refers to the apparent volume in which a drug is distributed (i.e., the parameter relating drug concentration to drug amount in the body).

The term “dose” as used herein refers to an amount of drug administered.

The term “efficacy” as used herein refers to the effectiveness of a topical pharmaceutical composition, measured by the degree of anesthetic effects that are observed after the topical pharmaceutical composition is administered to a subject.

The term “impurity” as used herein refers to an undesired substance in a composition. In some non-limiting embodiments, the amount of impurities may exist in the initial composition and/or may be formed after a certain period of time. In other non-limiting embodiments, impurities may be formed by the degradation of one or more components of the composition.

The term “ready to use” as used herein refers to a composition that is suitable for administration to a patient without dilution.

Prior investigators attempted to study certain attributes related to the application of cocaine, yet they did not use a ready to use, stable composition capable of producing the recited pharmacokinetic parameters. For example, Van Dyck et al., 1976, reports on a weight based administration of a 10% solution of cocaine hydrochloride on nasal mucosa. Administration of 1.5 mg/kg applied on the nasal mucosa produced a C_(max) between 120 ng/mL and 474 ng/mL. Patients also received diazepam and morphine sulfate 1 hour before receiving general anesthesia. Van Dyke 1976 did not report on standardized administration of a uniform amount of cocaine hydrochloride.

Van Dyke et al., 1978, compared pharmacokinetic values obtained via oral and intranasal administration of 2 mg/kg cocaine. The authors applied a 10% solution containing 115 mg to 246 mg topically on the nasal mucosa, or provided a gelatin capsule with the same amount of crystalline cocaine. The authors stated that the difference in peak plasma concentrations was not significant and that oral administration is at least as effective as the same dose given intranasally. The most substantial euphoric effects, i.e., the largest “high” rating obtained from intranasal application corresponded to an average cocaine plasma level of 93 ng/mL to 160 ng/mL.

Wilkinson et al., 1980, described plasma cocaine levels after intranasal and oral administration of cocaine. Wilkinson administered various doses ranging between 0.19 mg/kg to 2.0 mg/kg via a 10% aqueous solution, or crystalline cocaine at 2.0 mg/kg and 3.0 mg/kg. Wilkinson reported similar relative bioavailability values for intranasal and oral routes of administration.

Bromley and Hayward, 1988, described and compared the use of cocaine and cocaine with adrenaline for nasal surgery. All patients received substantial premedication, which included papaveretum and hyoscine, induction with thiopentone, and suxamethonium. Patients also used a Magill breathing system with nitrous oxide and oxygen with halothane. The authors state that the primary use of cocaine is for its vasoconstriction activity and its local anesthetic effect makes a secondary contribution to the general anesthesia. The authors found that adrenaline lowers the absorption of cocaine, and did not significantly change pulse rate and blood pressure.

Greinwald and Holtel, 1996, described topical application of cocaine with cotton pledgets. Greinwald reported that no prior studies exist for absorption of cocaine from cottonoid pledgets, and serum levels of cocaine were rarely detectable in plasma samples. If cocaine detection occurred, the amount measured did not correlate with either the amount of nasal absorption or the time of mucosal contact. Greinwald also reported that approximately 37% of cocaine is absorbed from a cottonoid pledget.

Fattinger et al., 2000, studied cocaine in the systemic circulation after oral and nasal dosing. The authors note that only a small portion of the nasally administered cocaine is absorbed through the nose, and the majority is absorbed through the gastrointestinal tract.

Lannett Company, Inc. markets and Roxane Laboratories, Inc. previously marketed topical cocaine hydrochloride solutions, but such products are not approved by the United States Food and Drug Administration as stable for the effective induction of local anesthesia when performing diagnostic procedures and surgeries on or through the mucous membranes of the nasal cavities in patients. There is a need for a stable topical cocaine hydrochloride solution, a method for applying that solution to create therapeutic levels of cocaine in patients, and a method for effectively and locally anesthetizing patients prior to performing diagnostic and surgical procedures.

Disclosed herein is a topically administered anesthetic pharmaceutical composition including cocaine hydrochloride. The composition may be used, for example, to anesthetize a body region of a subject prior to conducting a diagnostic, surgical, or post-operative procedure involving the body region. The pharmaceutical composition may be used in both outpatient and inpatient settings. Exemplary nasal procedures include nasal endoscopy, nasal endoscopy with debridement, laryngoscopy, nasal laryngoscopy, nasopharyngeal laryngoscopy, transnasal esophagoscopy, nasal stroboscopy, nasal endoscopy with polypectomy, nasal debridement, intraturbinate methylprednisolone acetate injection, turbinate reduction, sinuplasty, and nasal cauterization. Table 1 provides non-exhaustive examples of diagnostic and surgical procedures that may be conducted on the oral cavity and respiratory tract regions anesthetized using the pharmaceutical composition of the present disclosure.

TABLE 1 Oral cavity procedures Cleft palate evaluation, biopsy, and local tonsillectomy Respiratory tract Indirect and direct laryngoscopy, laryngography, procedures tracheoscopy, bronchoscopy, bronchography

In a non-limiting embodiment according to the present disclosure, a pharmaceutical composition adapted for reducing sensation in a body region of a patient comprises about 4% cocaine hydrochloride, by weight, and a preservative, in an aqueous solution.

In various non-limiting embodiments, the pharmaceutical composition can include cocaine hydrochloride in a concentration, by weight percent, based on the total weight of the pharmaceutical composition, of about 3.6% to about 4.4%, by weight, or any range or specific percentage subsumed within that range.

In certain non-limiting embodiments, the pharmaceutical composition can include one or more preservative compounds to inhibit microbial growth and/or reduce the rate of metabolic deterioration of the cocaine hydrochloride in the composition, increasing composition stability. In certain non-limiting embodiments, the preservative may be one or more compounds selected from sodium benzoate, antimol, benzoic acid, carboxybenzene sodium salt, benzoan sodny, benzalkonium chloride, cetrimonium bromide, benzethonium chloride, alkyltrimethylammonium bromide, benzalkonium chloride/edetic acid, edetic acid, amino aryl acid esters, phenol, methylparaben, ethylparaben, propylparaben, butylparaben, chlorobutanol, phenylmercuric nitrate, sorbic acid, potassium sorbate, chlorocresol, glycerol, benzyl alcohol, cetyl alcohol, stearyl alcohol, sorbic acid, chloroactamide, trichlorocarban, thimerosal, imidurea, bronopol, chlorhexidine, 4-chlorocresol, 4-chloroxylenol, dichlorophene, and hexachlorophene.

In certain non-limiting embodiments, the pharmaceutical composition includes sodium benzoate as a preservative. In certain non-limiting embodiments the pharmaceutical composition includes about 0.1%, by weight, of sodium benzoate or another preservative. In certain non-limiting embodiments, the sodium benzoate concentration in the pharmaceutical composition is greater than 0 and less than 5%, by weight, or is present at any value or in any range subsumed therein, such as, for example, 4%, 3%, 2%, 1%, greater than 0 to less than 1%, 0.01% to 1%, 0.05% to 0.50%, or 0.07% to 0.20%.

In certain non-limiting embodiments, the pharmaceutical composition further includes one or more acidulants to inhibit disintegration of the cocaine hydrochloride into metabolites and to adjust the pH of the aqueous pharmaceutical composition. In certain non-limiting embodiments, the acidulant is one or more of citric acid, citric acid anhydrous, citric acid monohydrate, sodium citrate, L-malic acid, D-malic acid, lactic acid, L(+)-tartaric acid, fumaric acid, sodium lactate, calcium lactate, L-lactic acid, calcium citrate, magnesium citrate, ferrous lactate, tripotassium citrate, trisodium citrate, and tricalcium citrate.

In certain non-limiting embodiments, the aqueous pharmaceutical composition includes, by weight, about 0.125% citric acid. In certain non-limiting embodiments, the concentration, in weight percent, of citric acid or other acidulant in the pharmaceutical composition is greater than 0 to less than 5%, or has any value or is within range subsumed therein such as, for example, greater than 0 to less than 3%, greater than 0 to less than 1%, 0.1%, 0.150%, 0.130%, 0.120%, 0.110%, 0.2%, 0.3%, 0.4%, 0.5%, 0.01% to 1%, 0.01% to 0.85%, 0.05% to 0.50%, or 0.02% to 0.70%.

Certain non-limiting embodiments of the aqueous pharmaceutical composition herein include about 4% cocaine hydrochloride, by weight, a preservative, and an acidulant in an aqueous solution at a pH ranging from 1 to 6, or having a pH of any value or falling within any range subsumed therein, such as, for example, from 1.5 to 5.5, from 2 to 5, from 2.5 to 4.5, from 3 to 4, or from 3.5 to 3.9.

Certain non-limiting embodiments of the pharmaceutical composition of the present disclosure including about 4% cocaine hydrochloride result in a cocaine AUC_(inf) ranging from 30.8 ng*h/mL to 79.0 ng*h/mL, following a topical application of the pharmaceutical composition to a body region of a subject for about 20 minutes. More generally, certain non-limiting embodiments of the pharmaceutical composition of the present disclosure including about 4% cocaine hydrochloride, by weight, result in a cocaine AUC_(inf) selected from the following group following a topical application of the pharmaceutical composition to a body region of a subject for about 20 minutes: from 25.0 ng*h/mL to 370.0 ng*h/mL, from 30.0 ng*h/mL to 200 ng*h/mL, from 40.0 ng*h/mL to 150.0 ng*h/mL, from 34.1 ng*h/mL to 60.3 ng*h/mL, from 20.7 ng*h/mL to 68.1 ng*h/mL, from 30.8 ng*h/mL to 79.0 ng*h/mL, 40.6 ng*h/mL to 150.0 ng/mL, from 88.0 ng*h/mL to 366 ng*h/mL, from 124.8 ng*h/mL to 241.2 ng*h/mL, from 59.0 ng*h/mL to 111 ng*h/mL, from 61.2 ng*h/mL to 179.6 ng*h/mL, 44.4 ng*h/mL, 47.2 ng*h/mL, 54.9 ng*h/mL, 85.0 ng*h/mL, 95.3 ng*h/mL, 120.4 ng*h/mL, 183 ng*h/mL, and 227 ng*h/mL.

In certain non-limiting embodiments of methods of using the pharmaceutical composition according to the present disclosure, a volume of the pharmaceutical composition is contacted with a body region of a subject for about 20 minutes. More generally, in certain non-limiting embodiments of methods of using the pharmaceutical composition according to the present disclosure, a volume of the pharmaceutical composition is contacted with a body region of a subject for greater than 0 to less than 45 minutes, or any value or range subsumed therein, such as, for example, from 1 minute to 40 minutes, from 5 minutes to 30 minutes, from 8 minutes to 25 minutes, from 10 minutes to 20 minutes, 30 minutes, 25 minutes, 24 minutes, 23 minutes, 22 minutes, 21 minutes, 19 minutes, 18 minutes, 17 minutes, 16 minutes, 15 minutes, 10 minutes, 5 minutes, or 3 minutes. In various non-limiting embodiments of the method, the pharmaceutical composition is an aqueous solution comprising cocaine hydrochloride, a preservative, and an acidulant, in any of the concentrations as described and disclosed herein.

The pharmacokinetic parameter C_(max) refers to the maximum (peak) serum concentration of a specific compound in the body of a subject after a pharmaceutical composition or compound has been administrated to the subject. One non-limiting embodiment herein is directed to a pharmaceutical composition for reducing sensation in a body region of a subject, wherein the composition is an aqueous solution including a preservative and about 4% cocaine hydrochloride by weight, and wherein the pharmaceutical composition results in a cocaine C_(max) ranging from 19.7 ng/mL to 54.3 ng/mL in the subject following a topical application of the pharmaceutical composition to a body region of a subject for about 20 minutes. In certain non-limiting embodiments, the cocaine C_(max) achieved following topical application of the pharmaceutical composition to a body region of a subject for about 20 minutes is within the range of from 10.0 ng/mL to 100.0 ng/mL, or has any value or falls within any range subsumed therein, such as, for example, from 20 ng/mL to 80 ng/mL, from 25 ng/mL to 70 ng/mL, from 30 ng/mL to 65 ng/mL, from 35 to 60 ng/mL, from 16.2 ng/mL to 85.2 ng/mL, from 20 ng/mL to 96 ng/mL, from 21.9 ng/mL to 93.7 ng/mL, from 29.6 ng/mL to 71.6 ng/mL, from 25.0 ng/mL to 51.2 ng/mL, from 19.7 ng/mL to 54.3 ng/mL, from 17.0 ng/mL to 52.2 ng/mL, from 21.8 ng/mL to 56.2 ng/mL, from 45.3 ng/mL to 89.3 ng/mL, 90 ng/mL, 85 ng/mL, 80 ng/mL, 75 ng/mL, 70 ng/mL, 67.3 ng/mL, 65 ng/mL, 60 ng/mL, 57.8 ng/mL, 55 ng/mL, 50 ng/mL, 50.7 ng/mL, 45 ng/mL, 40 ng/mL, 39 ng/mL, 38.1 ng/mL, 37 ng/mL, 34.6 ng/m, 35 ng/mL, 30.0 ng/mL, 25 ng/mL, 20 ng/mL, or 15 ng/mL.

The pharmacokinetic parameter T_(max) for a pharmaceutical composition or compound is the time after administration to a subject at which the C_(max) is observed in the subject. One non-limiting embodiment herein is directed to a pharmaceutical composition for reducing sensation in a body region of a subject, wherein the composition is an aqueous solution including a preservative and about 4% cocaine hydrochloride by weight, and wherein following a topical application of the pharmaceutical composition to the subject for about 20 minutes, a cocaine T_(max) of 0.09 h to 0.77 h is observed in the subject. In various non-limiting embodiments, following the topical application of the pharmaceutical composition to a body region of a subject, the observed cocaine T_(max) falls within the range from 0.01 h to 2 h, or has any value or falls within range subsumed therein, such as, for example, from 0.306 h to 1.87 h, from 0.205 h to 0.961 h, from 0.301 h to 0.595 h, from 0.435 h to 0.953 h, from 0.345 h to 0.517 h, from 0.095 h to 0.739 h, from 0.082 h to 0.739 h, from 0.092 h to 0.774 h, from 0.020 h to 1.00 h, from 0.030 h to 0.900 h, from 0.040 h to 0.800 h, from 0.030 h to 0.700 h, from 0.040 h to 0.600 h, 1.09 h, 1.20 h, 0.789 h, 0.583 h, 0.448 h, 0.433 h, 0.431 h, 0.417 h, or 0.694 h.

In a non-limiting embodiment herein, a pharmaceutical composition for reducing sensation in a body region of a subject includes about 4% cocaine hydrochloride, by weight, and a preservative, in an aqueous solution, wherein an absorptivity factor for cocaine ranging from 0.640 h⁻¹ to 0.687 h⁻¹ is achieved in the subject following a topical application of the pharmaceutical composition to the body region for about 20 minutes. In certain non-limiting embodiments, the absorptivity factor for cocaine resulting following the topical application of the pharmaceutical composition to the subject for about 20 minutes is in the range of from 0.100 h⁻¹ to 1.50 h⁻¹, or has any value or falls within any range subsumed therein, such as, for example, from 0.358 h⁻¹ to 0.522 h⁻¹, from 0.438 h⁻¹ to 0.466 h⁻¹, from 0.184 h⁻¹ to 0.233 h⁻¹, from 0.366 h⁻¹ to 0.372 h⁻¹, from 0.640 h⁻¹ to 0.687 h⁻¹, from 0.627 h⁻¹ to 0.690 h⁻¹, from 0.499 h⁻¹ to 0.866 h⁻¹, from 0.483 h⁻¹ to 0.789 h⁻¹, from 0.250 h⁻¹ to 1.0 h⁻¹, from 0.300 h⁻¹ to 0.900 h⁻¹, from 0.350 h⁻¹ to 0.800 h⁻¹, from 0.400 h⁻¹ to 0.700 h⁻¹, from 0.500 h⁻¹ to 0.600 h⁻¹, 0.227 h⁻¹, 0.370 h⁻¹, 0.456 h⁻¹, 0.487 h⁻¹, 0.545 h⁻¹, 0.878 h⁻¹, 0.964 h⁻¹, or 1.10 h⁻¹.

In a non-limiting embodiment herein, a pharmaceutical composition for reducing sensation in a body region of a subject includes about 4% cocaine hydrochloride, by weight, and a preservative, in an aqueous solution, and wherein topical administration of the pharmaceutical composition to the body region for about 20 minutes results in a urinary recovery of cocaine from the subject ranging from 49.9 μg to 184.1 μg over a period of 12 hours from the time of administration to the subject. In certain non-limiting embodiments, following the topical application of the pharmaceutical composition to the body region for about 20 minutes, a urinary recovery of cocaine from the subject is observed ranging from 20 μg to 350 μg, or having any value or falling within any range subsumed therein, over a period of 12 hours from the time of administration. Certain other non-limiting embodiments of the pharmaceutical composition result in a urinary recover of cocaine from the subject in the range of from 49.9 μg to 184.1 μg, from 38.9 μg to 290 μg, from 38.3 μg to 166 μg, from 30 μg to 300 μg, from 35 μg to 250 μg, from 40 μg to 200 μg, or from 45 μg to 150 μg over a period of 12 hours from the time of topical administration of the composition to a body region of a subject.

The stability of the aqueous pharmaceutical composition comprising cocaine hydrochloride that is described herein can be evaluated by the measuring the cocaine hydrochloride concentration remaining within the composition after the composition has been stored over a period of time at controlled temperatures and controlled relative humidity conditions. In a non-limiting embodiment herein, a ready to use pharmaceutical composition is provided originally including about 4% cocaine hydrochloride, by weight, and a preservative in an aqueous solution at a pH of 2 to 4, wherein the cocaine hydrochloride concentration remains at greater than 3%, by weight, after the composition is stored for 12 months at a temperature ranging from 23° C. to 27° C. and a relative humidity ranging from 55% to 65%. In various non-limiting embodiments, the cocaine hydrochloride concentration in the ready to use pharmaceutical composition after the composition is stored for 12 months at a temperature ranging from 23° C. to 27° C. and a relative humidity ranging from 55% to 65% is greater than 3.1%, greater than 3.2%, greater than 3.3%, greater than 3.4%, greater than 3.5%, greater than 3.6%, greater than 3.7%, greater than 3.8%, greater than 3.9%, or greater than 3.95%.

In certain non-limiting embodiments herein, a ready to use pharmaceutical composition originally including about 4% cocaine hydrochloride, by weight, and a preservative, in an aqueous solution at a pH of 2 to 4, retains a cocaine hydrochloride concentration greater than 3.6%, by weight, after the composition is stored for 12 months at a temperature ranging from 23° C. to 27° C. and a relative humidity ranging from 55% to 65%.

In certain non-limiting embodiments herein, a ready to use pharmaceutical composition originally including about 4% cocaine hydrochloride, by weight, and a preservative, in an aqueous solution at a pH of 2 to 4, retains a cocaine hydrochloride concentration greater than 3.4%, by weight, after the composition has been stored for a time selected from 12 months, 18 months, 20 months, 24 months, 30 months, 36 months at a temperature ranging from 23° C. to 27° C. and a relative humidity ranging from 55% to 65%.

In certain non-limiting embodiments herein, a ready to use pharmaceutical composition originally including about 4% cocaine hydrochloride, by weight, and a preservative, in an aqueous solution at a pH of 2 to 4, retains a cocaine hydrochloride concentration greater than 3.4%, by weight, after the composition is stored for 6 months at a temperature ranging from 28° C. to 32° C., and a relative humidity ranging from 60% to 70%. In various non-limiting embodiments, the cocaine hydrochloride concentration in the ready to use pharmaceutical composition after the composition is stored for 6 months at a temperature ranging from 28° C. to 32° C., and a relative humidity ranging from 60% to 70% is greater than 3.1%, greater than 3.2%, greater than 3.3%, greater than 3.4%, greater than 3.5%, greater than 3.6%, greater than 3.7%, greater than 3.8%, greater than 3.9%, or greater than 3.95%.

In certain non-limiting embodiments herein, a ready to use pharmaceutical composition originally including about 4% cocaine hydrochloride, by weight, and a preservative, in an aqueous solution at a pH of 2 to 4, retains a cocaine hydrochloride concentration greater than 3.4%, by weight, after the composition is stored for a time selected from 6 months, 9 months, 12 months, 18 months, 20 months, 24 months, 30 months, and 36 months, at a temperature ranging from 28° C. to 32° C., and a relative humidity ranging from 60% to 70%.

In certain non-limiting embodiments herein, a ready to use pharmaceutical composition originally including about 4% cocaine hydrochloride, by weight, and a preservative in an aqueous solution at a pH of 2 to 4, retains a cocaine hydrochloride concentration greater than 3.4%, by weight, after the composition is stored for at least 1 month at a temperature ranging from 38° C. to 42° C., and a relative humidity ranging from 70% to 80%. In various non-limiting embodiments, the cocaine hydrochloride concentration in the ready to use pharmaceutical composition after the composition is stored for at least 1 month at a temperature ranging from 38° C. to 42° C., and a relative humidity ranging from 70% to 80% is greater than 3.1%, greater than 3.2%, greater than 3.3%, greater than 3.4%, greater than 3.5%, greater than 3.6%, greater than 3.7%, greater than 3.8%, greater than 3.9%, or greater than 3.95%.

In various non-limiting embodiments, a ready to use pharmaceutical composition is provided originally including about 4% cocaine hydrochloride, by weight, and a preservative in an aqueous solution at a pH of 2 to 4, wherein the cocaine hydrochloride concentration remains at greater than 3.4%, by weight, after the composition is stored for a time selected from 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, and 8 months at a temperature ranging from 38° C. to 42° C. and a relative humidity ranging from 70% to 80%.

Cocaine is predominantly metabolized in the human body, with little excreted in an unchanged form in the urine. In humans, cocaine is rapidly metabolized by hydrolytic pathways to form two major metabolites, benzoylecgonine (BE) and ecgonine methyl ester (EME), and by oxidative demethylation to form a minor metabolite, norcocaine, which has pharmacologic activity. FIG. 1 shows the metabolic pathways to form BE and EME. Ecgonine, a metabolite formed after sequential de-esterification steps, has also been observed. BE has been observed to be the major metabolite in the plasma after all routes of administration of cocaine.

The present inventors developed a highly storage stable pharmaceutical composition that inhibits the breakdown of cocaine hydrochloride in the pharmaceutical composition and provides a composition with a consistently therapeutically effective concentration of cocaine hydrochloride, including a limited concentration of impurities, over an extended time period. For example, one non-limiting embodiment of a storage stable pharmaceutical composition according to the present disclosure initially includes about 4% cocaine hydrochloride, by weight, and a preservative, in an aqueous solution at a pH of 2 to 4, wherein the composition comprises no more than 7% of total impurities, by weight, after the composition has been stored for 20 months at a temperature ranging from 23° C. to 27° C. and a relative humidity ranging from 55% to 65%.

In various non-limiting embodiments, the storage stable pharmaceutical composition can comprise total impurities in a concentration of no more than 15%, by weight, or having any value or within any range subsumed therein, such as, for example, less than 10%, less than 9%, less than 8%, less than 7%, less than 6%, less than 5%, less than 4%, less than 3%, or less than 2%, after the composition has been stored for 20 months at a temperature ranging from 23° C. to 27° C. and a relative humidity ranging from 55% to 65%.

In various embodiments, the storage stable pharmaceutical composition initially comprises about 4% cocaine hydrochloride, by weight, and a preservative, in an aqueous solution at a pH of 2 to 4, and the composition comprises no more than 6.6% of benzoylecgonine, by weight, after the composition has been stored for 20 months at a temperature ranging from 23° C. to 27° C. and a relative humidity ranging from 55% to 65%.

In various embodiments, the storage stable pharmaceutical composition can comprise no more than 10% benzoylecgonine (BE), by weight, or any value or range of BE concentration subsumed therein, such as, for example, no more than 9.5%, no more than 9.0%, no more than 8.5%, no more than 8.0%, no more than 7.5%, no more than 7.3%, no more than 7.0%, no more than 6.5%, no more than 6.0%, or no more than 5.5% after storage for a period of 20 months at a temperature ranging from 23° C. to 27° C. and a relative humidity ranging from 55% to 65%.

In a non-limiting embodiment, a storage stable pharmaceutical composition initially comprises about 4% cocaine hydrochloride, by weight, and a preservative, in an aqueous solution at a pH of 2 to 4, and wherein the composition comprises no more than 8% of total impurities, by weight, after the composition has been stored for 12 months at a temperature ranging from 28° C. to 32° C. and a relative humidity ranging from 60% to 70%.

In various non-limiting embodiments, the storage stable pharmaceutical composition originally including about 4% cocaine hydrochloride, by weight, and a preservative in an aqueous solution at a pH of 2 to 4, comprises no more than 7.3% benzoylecgonine, by weight, after the composition is stored for 20 months at a temperature ranging from 23° C. to 27° C. and a relative humidity ranging from 55% to 65%.

In various non-limiting embodiments, the storage stable pharmaceutical composition originally including about 4% cocaine hydrochloride, by weight, and a preservative in an aqueous solution at a pH of 2 to 4, comprises no more than 5.9% benzoylecgonine, by weight, after the composition is stored for 4 months at a temperature ranging from 38° C. to 42° C. and a relative humidity ranging from 70% to 80%.

In various non-limiting embodiments, the storage stable pharmaceutical composition originally including about 4% cocaine hydrochloride, by weight, and a preservative in an aqueous solution at a pH of 2 to 4, comprises no more than 8.8% benzoylecgonine, by weight, after the composition is stored for 6 months at a temperature ranging from 38° C. to 42° C. and a relative humidity ranging from 70% to 80%.

In a non-limiting embodiment, a storage stable pharmaceutical composition comprises about 4% cocaine hydrochloride, by weight, and a preservative, in an aqueous solution at a pH of 2 to 4, wherein the composition comprises no more than 10% of total impurities, by weight, after the composition has been stored for 6 months at a temperature ranging from 38° C. to 42° C. and a relative humidity ranging from 70% to 80%. In various non-limiting embodiments, the storage stable pharmaceutical composition, after storage for 6 months at a temperature ranging from 38° C. to 42° C. and a relative humidity ranging from 70% to 80%, can comprise a total impurities concentration, by weight, of no more than 15%, or having any value or within any range subsumed therein, such as for example, less than 10%, less than 9%, less than 8%, less than 7%, less than 6%, less than 5%, less than 4%, less than 3%, or less than 2%.

The present disclosure also encompasses methods of using a pharmaceutical composition as an anesthetic prior to conducting a medical or diagnostic procedure on a subject. For example, in a non-limiting embodiment, a method of administering a topical anesthetic solution comprising cocaine hydrochloride to a subject to reduce sensation in a body region of the subject comprises soaking a number of (e.g., four) absorbent articles with the solution, and contacting the soaked absorbent articles with a nasal mucous membrane of the patient for at least about 20 minutes, wherein the method achieves a cocaine AUC_(inf) in the subject ranging from 30.8 ng*h/mL to 79.0 ng*h/mL.

In various non-limiting embodiments of the method, the topical solution of the method is an aqueous solution comprising cocaine hydrochloride, a preservative, and an acidulant in any of the concentrations as described herein. In one non-limiting embodiment, the topical solution comprises about 4% by weight cocaine hydrochloride.

In various alternative non-limiting embodiments, the method can include contacting the soaked absorbent articles with the nasal mucous membrane of the subject for greater than 1 minute, or for any value or within any range subsumed therein, such as, for example, greater than 2 minutes, from 3 minutes to 50 minutes, from 4 minutes to 45 minutes, from 5 minutes to 30 minutes, from 6 minutes to 40 minutes, from 7 minutes to 35 minutes, from 8 minutes to 30 minutes, from 9 minutes to 25 minutes, from 10 minutes to 20 minutes, 5 minutes, 6 minutes, 7 minutes, 8 minutes, 9 minutes, 10 minutes, 11 minutes, 15 minutes, 20 minutes, greater than 5 minutes, greater than 10 minutes, greater than 15 minutes, or greater than 20 minutes.

In various non-limiting embodiments of the method wherein the topical solution comprises about 4% cocaine hydrochloride, any of the values previously described herein for cocaine AUC_(inf), cocaine C_(max), cocaine T_(max), and cocaine urinary recovery are achieved following a topical application of 4% cocaine hydrochloride to a subject for 20 minutes.

In various non-limiting embodiments, the absorbent articles can comprise cottonoid pledgets. According to certain non-limiting embodiments, each cottonoid pledget can have a size and an absorbency sufficient to absorb up to about 1 mL of a pharmaceutical solution comprising cocaine hydrochloride according to the present disclosure. In various non-limiting embodiments, the cottonoid pledgets include height dimensions ranging from 0.75 cm to 3.0 cm in height, or any value or range subsumed therein, such as for example, from 1.0 cm to 2.5 cm, or from 1.3 cm to 2.0 cm. In various non-limiting embodiments, each of the cottonoid pledgets includes length dimensions ranging from 3.0 cm to 8.0 cm, or any value or range subsumed therein, such as for example, from 4.0 cm to 7.0 cm, or from 5.0 to 6.0 cm.

In various non-limiting embodiments, a method according to the present disclosure can further include removing the absorbent article from contact with the mucous membrane, where following removal of the absorbent article from contact with the mucous membrane of the subject, the absorbent article retains up to 99% of the active agent absorbed therein. In certain non-limiting embodiments, the absorbent article retains up to 95%, up to 90%, up to 85%, up to 80%, up to 75%, up to 70%, up to 65%, up to 60%, up to 50%, 61%, 62%, 63%, 64%, 65%, or 66% of the original amount of active agent absorbed therein.

In a non-limiting embodiment, a method according to the present disclosure for administering a topical solution comprising about 4%, by weight, cocaine hydrochloride to a subject to reduce sensation in a body region of the subject comprises soaking a plurality of (e.g., four) absorbent articles with the solution, and contacting the absorbent articles with a nasal mucous membrane of the subject for at least about 20 minutes, wherein the method achieves a cocaine T_(max) in the subject ranging from 0.09 h to 0.77 h.

In certain embodiments, the method can include contacting the absorbent articles with the nasal mucous membrane of the patient for any and all time periods as previously described and disclosed in the methods herein.

In various embodiments of the method, the method can achieve a cocaine C_(max) ranging from 19.7 ng/mL to 54.3 ng/mL, and an absorptivity factor for cocaine in the patient ranging from 0.640 h⁻¹ to 0.687 hW.

In a non-limiting embodiment, a method according to the present disclosure for administering a topical anesthetic solution comprising about 4%, by weight, cocaine hydrochloride to a subject comprises soaking a plurality of (e.g., four) absorbent articles with the solution, and contacting the absorbent articles with a nasal mucous membrane of the subject for at least about 20 minutes, wherein a urinary recovery of cocaine ranges from 38.9 μg to 289.5 μg over a period of 32 hours from the time of administration. In various non-limiting embodiments, the method of administering the topical anesthetic solution to a patient can result in a urinary recovery of cocaine ranging from 5 μg to 400 μg, or any value or range subsumed therein, such as for example, from 7 μg to 300 μg, from 7.1 μg to 269.9 μg, from 18.3 μg to 389.7 μg, from 20 μg to 375 μg, from 30 μg to 200 μg, or from 38.34 μg to 166.16 μg over a period of 32 hours from the time of administration of the anesthetic solution to a subject.

In various non-limiting embodiments, the method of administering the topical anesthetic solution comprising cocaine hydrochloride to a subject can result in a renal clearance of cocaine from the subject ranging from 0.01 L/h to 5.0 L/h, or having any value or range subsumed therein, such as for example, from 0.85 L/h to about 4.81 L/h, from 0.05 L/h to 4.0 L/h, from 0.15 L/h to 3.43 L/h, from 0.20 L/h to 3.60 L/h, or from 0.61 L/h to 3.39 L/h over a period of 32 hours from the time of administration.

In various non-limiting embodiments, the method of administering the topical anesthetic solution comprising cocaine hydrochloride to a subject can result in a urinary recovery of ecgonine methyl ester from the subject ranging from 321.5 μg to 1868.5 μg over a period of 32 hours from the time of administration of the solution. In certain non-limiting embodiments, the method of administering the topical anesthetic to a subject can result in a urinary recovery of ecgonine methyl ester from the subject ranging from 200 μg to 2500 μg, or any value or range subsumed therein, such as, for example, from 367.1 μg to 2482.9 μg, from 524.4 μg to 1571.65 μg, from 300 μg to 2000 μg, from 275 μg to 1500 μg, from 250 μg to 1000, or from 321.5 μg to 1868.5 μg over a period of 32 hours from the time of administration of the anesthetic solution.

In various non-limiting embodiments, the method of administering the topical anesthetic solution comprising cocaine hydrochloride to a subject can result in a urinary recovery of benzoylecgonine from the patient ranging from 400 μg to 7000 μg, or having any value or within range subsumed therein, such as, for example, from 469 μg to 5059 μg, from 500 μg to 4500 μg, from 936 μg to 6540 μg, or from 1000 μg to 4000 μg over a period of 32 hours from the time of administration of the solution.

In a non-limiting embodiment, a method according to the present disclosure for administering a topical solution including cocaine hydrochloride to a subject to reduce sensation in a body region of the subject comprises soaking a plurality of (e.g., four) absorbent articles with an aqueous solution including about 4%, by weight, cocaine hydrochloride, and contacting the absorbent articles with a nasal mucous membrane of the patient for at least about 20 minutes, wherein the method achieves an ecgonine methyl ester C_(max) ranging from 1.8 ng/mL to 13.2 ng/mL in the subject. In various non-limiting embodiments, the method can result in an ecgonine ethyl ester C_(max) ranging from 1 ng/mL and 25 ng/mL, or having any value or within any subrange subsumed therein, such as for example, from 3.7 ng/mL to 16.3 ng/mL, from 1.8 ng/mL to 13.2 ng/mL, from 3 ng/mL to 15 ng/mL, from 6 to 17.8 ng/mL, from 8 ng/mL to 20 ng/mL.

In various non-limiting embodiments of the method, the method can result in a benzoylecgonine C_(max) ranging from 8.4 ng/mL to 103 ng/mL. In certain non-limiting embodiments, the method can achieve a benzoylecgonine C_(max) ranging from 5 ng/mL to 225 ng/mL, or having any value or within any subrange subsumed therein, such as for example, from 21.3 ng/mL to 219.5 ng/mL, from 8.4 ng/mL to 103 ng/mL, from 10 ng/mL to 90.0 ng/mL, from 12.3 ng/mL to 102.7 ng/mL, or from 15 ng/mL to 90 ng/mL.

Administration of the anesthetic solution comprising cocaine hydrochloride described herein to the nasal mucous membranes in the manner described herein reduces sensation in that body region. Reduction in sensation produced by local analgesia can be assessed using the von Frey filament test and a visual numeric rating scale (VNRS) by which the subject self-reports pain intensity (0=no pain and 10=worst possible pain). A clinician can perform a von Frey filament test to assess the level of efficacy of sensation reduction upon administering the anesthetic solution. Generally, the clinician can choose one or both nostrils for pre-procedural testing based upon the scheduled procedure. Each subject can be asked to close his/her eyes to prevent any visual clues. In this test, a large von Frey filament (6.10; 100 g) is initially applied to the nasal ala, vestibule, nasal hairs, and anterior septum to help the subject discriminate between these structures. The nasal ala are gently retracted laterally with a blunt-ended, single-pronged retractor to provide easy access to the nasal septum during measurements. The filament is pushed, at an approximately perpendicular angle, against the anterior nasal septum until it bends, so that a standardized force is applied to the anterior nasal septum, and the subject is asked to rate the pain (and not pressure) experienced using the VNRS.

In addition to utilizing a von Frey filament/VNRS protocol to assess efficacy, observed levels of cocaine and its metabolites in the blood can be equated with efficacy of pain reduction. Thus, for example, following administration of the anesthetic solution described herein to nasal mucous membranes in the manner described herein, the clinician can observe serum concentration levels of cocaine, ecgonine methyl ester, and benzoylecgonine in the subject and thereby assess corresponding sensation reduction. Those levels may be used to determine whether, for example, a secondary administration of a local anesthetic composition is necessary.

In certain embodiments of methods according to the present disclosure, the method includes administering a second anesthetic to the patient if the observed C_(max) of cocaine metabolite ecgonine methyl ester is less than 1.8 ng/mL after administration of a pharmaceutical composition as described herein in a manner as described herein. In certain non-limiting embodiments, the method can comprise administering a second anesthetic if the ecgonine methyl ester C_(max) is less than 7 ng/mL, or is any value or falls within any range subsumed therein, such as for example, less than 6 ng/mL, less than 5 ng/mL, less than 4 ng/mL, less than 3.7 ng/mL, less than 2 ng/mL, less than 1 ng/mL, or less than 0.5 ng/mL. In certain embodiments, the second anesthetic solution can be or include, for example, lidocaine, lidocaine hydrochloride, bupivacaine, dibucaine, tetracaine, and salts thereof, or the like, or another topical anesthetic solution.

In a non-limiting embodiment according to the present disclosure, a method of administering a topical solution comprising cocaine hydrochloride to a subject to reduce sensation in a body region of the subject comprises soaking a plurality of (e.g., four) absorbent articles with a solution comprising cocaine hydrochloride. The solution can include a cocaine hydrochloride concentration of about 4%, by weight. The method can further include contacting the absorbent articles with a nasal mucous membrane of the subject for at least about 20 minutes, whereby the method achieves a benzoylecgonine C_(max) in the subject ranging from 8.4 ng/mL to 103 ng/mL. In certain non-limiting embodiments, the method can further comprise administering a second anesthetic solution to the subject if the benzoylecgonine C_(max) is less than 25 ng/mL.

In various embodiments, the pharmaceutical compositions comprising cocaine hydrochloride that are described herein can include coloring additives (colorants) to provide the solution with a specific desired color. Those having ordinary skill will be able to readily identify and procure suitable coloring additives for the compositions herein.

According to aspects of the present disclosure, local anesthesia can be achieved prior to performing diagnostic, surgical, or post-operative procedures on or through a mucous membrane of the nasal cavities of a subject by soaking one or more cottonoid pledgets or other absorbent articles with about 1 mL of an anesthetic aqueous solution per article, wherein the solution includes, by weight, about 4% cocaine hydrochloride, about 0.1% sodium benzoate, about 0.125% citric acid, and optionally a coloring additive. The method also includes contacting the soaked absorbent articles with a nasal mucous membrane of the patient for at least about 20 minutes. The diagnostic, surgical, or post-operative procedure can then be conducted.

The present disclosure also encompasses a method for effectively anesthetizing a body region of a subject comprising immersing at least one absorbent article in an aqueous pharmaceutical composition including about 3.6% to about 4.4% cocaine hydrochloride, about 0.07% to about 0.20% sodium benzoate, and about 0.125% citric acid, wherein the aqueous pharmaceutical composition of the method has a pH between 2 and 4. The at least one absorbent article and the aqueous pharmaceutical composition absorbed therein is contacted with a mucous membrane of the patient for a time period so as to reduce sensation and achieve a visual numeric rating score of 0 in the body region proximate to the mucous membrane upon filament testing.

In certain non-limiting embodiments of the method, the absorbent article that is contacted with the aqueous pharmaceutical composition is a cottonoid pledget with absorbency sufficient to absorb at least about 1 mL of the aqueous pharmaceutical composition. In certain non-limiting embodiments, the cottonoid pledget retains up to 90% of the solution when removed from contact with the patient.

The pharmaceutical composition described herein may be used as a topical anesthetic to anesthetize a body region of hepatically impaired and renally impaired subjects. For example, a method according to the present disclosure for effectively anesthetizing a body region of a hepatically or renally impaired subject includes immersing an absorbent article in an aqueous pharmaceutical composition comprising about 3.6% to about 4.4% cocaine hydrochloride, about 0.07% to about 0.20% sodium benzoate, and about 0.125% citric acid, wherein the aqueous pharmaceutical composition has a pH between 2 and 4. The absorbent article and the aqueous pharmaceutical composition absorbed therein are contacted with a mucous membrane of the subject for a time period sufficient to anesthetize the body region. For example, the time period may be sufficient to achieve a visual numeric rating score of 0 in the body region proximate to the mucous membrane upon filament testing. With regard to hepatically impaired patients, the step of contacting an absorbent article containing the aqueous pharmaceutical composition with the mucous membrane is not repeated within 24 hours from the time of initial administration.

By monitoring the levels of the pharmacokinetic parameters, the methods and pharmaceutical compositions described herein can be applied to achieve successful analgesia (indicating a VNRS score of 0=no pain) before a medical procedure is initiated.

For example, in renally impaired subjects, pharmacokinetic parameters confirmed that successful analgesia (indicating a VNRS score of 0=no pain) can be achieved in patients using the methods and compositions herein, and without harming those subjects. For example, the following pharmacokinetic values were observed in renally impaired patients administered pharmaceutical compositions as described by methods described herein involving contacting soaked absorbent articles with nasal mucous membranes of the subjects, and without harm to the subjects: cocaine C_(max) ranging from 21.9 ng/mL to 93.7 ng/mL; T_(max) value for cocaine ranging from 0.301 h to 0.595 h; AUC_(inf) for cocaine ranging from 61.2 ng*h/mL to 179.6 ng*h/mL; apparent clearance of cocaine ranging from 645 L/h to 2389 L/h; absorptivity factor for cocaine ranging from 0.358 h⁻¹ to 0.522 h⁻¹; urinary recovery of cocaine ranging from 7.1 μg to 269.9 μg, and renal clearance for cocaine ranging from 0.528 L/h to 1.912 L/h over a period of 32 hours from the time of the administration. In certain embodiments of methods herein, one may compare the measured value for one or more of these parameters with these ranges to assess efficacy of anesthetization. Also, where one or more of the pharmacokinetic parameters falls outside of the known parameter range for sufficient and safe anesthetization of the region (successful analgesia), such as for example, where a C_(max) of ecgonine methyl ester in the patient falls below 6 ng/mL and/or if the C_(max) of benzoylecgonine in the patient falls below 21.3 ng/mL, the method can further include administering a second anesthetic composition to the subject.

Similarly, in hepatically impaired subjects, pharmacokinetic parameters confirmed that successful analgesia (indicating a VNRS score of 0=no pain) can be achieved in patients using the methods and compositions herein, and without harming those subjects. For example, the following pharmacokinetic values were observed in hepatically impaired patients administered pharmaceutical compositions as described by methods described herein involving contacting soaked absorbent articles with nasal mucous membranes of the subjects, and without harm to the subjects: cocaine C_(max) ranging from 16.2 ng/mL to 85.2 ng/mL; T_(max) value for cocaine ranging from 0.306 h to 1.874 h; AUC_(h) for cocaine ranging from 88 ng*h/mL to 366 ng*h/mL; apparent clearance of cocaine ranging from 390 L/h to 1344 L/h; absorptivity factor for cocaine ranging from 0.184 h⁻¹ to 0.233 h⁻¹; and renal clearance for cocaine that ranges from 0.076 L/h to 1.918 L/h over a period of 32 hours from the time of the administration. In certain embodiments of methods herein, one may compare the measured value for one or more of these parameters with these ranges to assess efficacy of anesthetization. Also, where one or more of the pharmacokinetic parameters falls outside of the known parameter range for sufficient and safe anesthetization of the region (successful analgesia), the method can further include administering a second anesthetic composition to the subject.

The examples that follow are intended to further describe certain non-limiting embodiments, without restricting the scope of the present invention. Persons having ordinary skill in the art will appreciate that variations of the following examples are possible within the scope of the invention, which is defined solely by the claims.

Example 1

Single-dose plasma and urinary pharmacokinetics of the pharmaceutical composition following intranasal administration was characterized in this study. This was a single-dose study in 30 healthy volunteers. The objective of the study was to examine the systemic pharmacokinetics of the pharmaceutical composition following acute, topical intranasal administration.

Materials and Methods

A single dose of a pharmaceutical composition was administered to both nostrils using cottonoid pledgets. The composition was an aqueous solution including 40 mg/mL cocaine hydrochloride, 1.25 mg/mL citric acid, 1.00 mg/mL sodium benzoate, a colorant (0.02 mg/mL D&C Yellow No. 10, 0.02 mg/mL FD&C Green No. 3), and 957.7 mg/mL water. Four mL of the pharmaceutical composition was poured into a standard medicine cup and four cottonoid pledgets (approximately 1.3 cm×4 cm) were added to this solution and allowed to soak for 10 minutes. Each pledget absorbed approximately 1 mL of pharmaceutical composition (i.e., 40 mg cocaine hydrochloride). Two soaked pledgets were placed into each nasal cavity of the subject and against the anterior septum for 20 minutes; thus, a total dose of 160 mg of cocaine hydrochloride was administered.

Blood samples were collected predose (30 minutes before pledget insertion), and 7.5, 15, 20, 30, 45, 60, 75, 90 and 105 minutes and 2, 3, 4, 6, 8, 10, and 12 hours from the start of application of the pharmaceutical composition. Plasma concentrations of cocaine, BE, and EME were determined using a validated liquid chromatography-tandem mass spectrometry (LC-MS/MS) method with a lower limit of quantification (LLOQ) of 5 ng/mL for cocaine, 100 ng/mL for BE, and 50 ng/mL for EME. A 25-μL aliquot of each stabilized plasma sample was processed by liquid-liquid extraction. The compounds were detected and quantified by LC-MS/MS in positive ion mode on an MDS Sciex API 4000 equipped with a TURBOIONSPRAY® interface. Calibration curves were obtained by performing a linear regression (weighted 1/x²) on the calibration standards.

Plasma pharmacokinetic parameters were analyzed using noncompartmental methods. The effect of gender on C_(max), T_(max), AUC_(last), AUC_(inf), and t_(1/2) was determined. The effects of age, body weight, and BMI on AUC_(last) were determined.

Urine samples were collected predose and at the following intervals from the start of intranasal application of the pharmaceutical composition: 0-2 hours, 2-4 hours, 4-8 hours, and 8-12 hours. Urine concentrations of cocaine, BE, and EME were determined using a validated LC-MS/MS method with an LLOQ of 5 ng/mL for cocaine, 100 ng/mL for BE, and 50 ng/mL for EME. A 25-μL aliquot of each urine sample was processed by liquid-liquid extraction. The compounds were detected and quantified by LC-MS/MS in positive ion mode on an MDS Sciex API 4000 equipped with a TURBOIONSPRAY® interface. Calibration curves were obtained by performing a linear regression (weighted 1/x²) on the calibration standards.

Urinary pharmacokinetic parameters were analyzed using noncompartmental methods. Urinary pharmacokinetic parameters included total urinary recovery (μg), urinary recovery as a percentage of dose, and renal clearance (CLr; cocaine only).

Results

A total of 30 subjects (14 males and 16 females) with a mean age of 46.1 years (range, 22 to 78 years) and mean BMI of 25.5 kg/m² (range, 19.6 kg/m² to 31.6 kg/m²) were enrolled; most subjects (96.7%) were white.

Cocaine was rapidly absorbed during the study drug exposure period. C_(max) ranged from 7.93 ng/mL to 70.3 ng/mL with mean C_(max) (37.0±17.3 ng/mL) observed shortly after the time of pledget removal (T_(max) of 0.43±0.34 hours) (see FIG. 2 and Table 2 below). Plasma concentrations then fell rapidly, with a mean t_(1/2) of 1.04±0.35 h. Cocaine concentrations fell below the LLOQ (5 ng/mL) between 1.5 h and 4 h after dosing.

TABLE 2 Cocaine plasma pharmacokinetic parameters after an intranasal dose of pharmaceutical composition. Geo- Geo- metric metric Parameter Units n Mean SD CV Mean SD C_(max) ng/mL 30 37.0 17.3 46.7 32.8 1.69 T_(max) h 30 0.433 0.341 78.6 0.374 1.59 C_(last) ng/mL 30 7.18 1.40 19.5 7.05 1.21 T_(last) h 30 2.40 0.709 29.5 2.31 1.31 AUC_(last) ng h/mL 30 38.4 20.2 52.5 34.2 1.61 AUC_(inf) ng h/mL 19 54.9 24.1 43.8 50.3 1.54 t_(1/2) h 25 1.04 0.349 33.7 0.975 1.44 MRT h 19 1.56 0.45 28.9 1.50 1.34 CL/F L/h 19 3096 1276 41.2 2843 1.54 CL/F mL/min 19 51601 21264 41.2 47375 1.54 Vd/F L 19 3877 1266 32.6 3680 1.40 % % 19 18.7 5.90 31.6 17.7 1.41 EXTRAP % EXTRAP = area under the concentration-time curve extrapolated after the time of last observed quantifiable concentration; AUC_(inf) = area under the concentration-time curve from time 0 to infinity; AUC_(last) = area under the concentration-time curve from time 0 to the time of the last measurable concentration; C_(last) = last observed quantifiable concentration; CL/F = apparent clearance; C_(max) = maximum concentration; CV = coefficient of variation; MRT = mean residence time; SD = standard deviation; t_(1/2), = half-life; T_(last) = time of last observed quantifiable concentration; T_(max) = time of maximum concentration; Vd/F = apparent volume of distribution

Apparent clearance (CL/F) was 3,096 L/hr. A comparison of CL/F to the systemic clearance (CL) of intravenous cocaine (32 mL/min/kg or approximately 134 L/h) suggests a rough estimate that only 4% of the 160 mg dose of the pharmaceutical composition was absorbed intact during the 20-minute exposure period.

Urine pharmacokinetic parameters for cocaine are summarized in Table 3 below. Cocaine was recovered in urine with a time course similar to that in plasma (FIG. 3). The majority of excreted cocaine was recovered in the 0-2 h collection interval. Although not detectable in plasma, BE and EME were recovered in urine during the 0-12 h collection period. Urinary excretion of BE and EME increased over time, with the highest amounts of both metabolites recovered in the 4-8 h collection interval. Urinary recovery of the metabolites continued at 8-12 h, suggesting that additional amounts of BE and EME were excreted at time points beyond the last collection. Although neither metabolite was detectable in the plasma, these data suggest that both BE and EME were present in the plasma for an extended (>12 h) time after dosing, but at levels that did not exceed 100 ng/mL and 50 ng/mL, respectively.

TABLE 3 Urine pharmacokinetic parameters after an intranasal dose of the pharmaceutical composition. Total Urinary Recovery, μg^(a) Cocaine BE EME n 30 30 30 Mean 117 816 275 SD 67.1 440 113 Median 114 769 276 Geometric mean 96.5 713 252 Urinary Recovery, % dose^(a) Cocaine BE EME Total n 30 30 30 30 Mean 0.0729 0.534 0.262 0.869 SD 0.0419 0.288 0.108 0.362 Median 0.0714 0.504 0.263 0.804 Geometric mean 0.0603 0.467 0.240 0.801 Renal Clearance of Cocaine L/h mL/min n 25 25 Mean 2.83 47.2 SD 1.98 33.0 Median 2.56 42.7 Geometric mean 2.23 37.2 ^(a)Metabolite recovery is expressed as cocaine equivalents BE = benzoylecgonine; EME = ecgonine methyl ester; SD = standard deviation

Effect of Intrinsic Factors on Pharmacokinetics

The effect of intrinsic factors (i.e., age, gender, body weight, and BMI) on the pharmacokinetic parameters of cocaine following topical nasal administration of the pharmaceutical composition was examined in Example 1.

Subject Gender

Cocaine exposure (i.e., C_(max), AUC_(last), and AUC_(inf)) was slightly higher in females than males whereas T_(max) and t_(1/2) were similar in males and females (Table 4). A higher range of cocaine exposure (i.e., AUC_(last)) was seen in females compared to males (FIG. 4).

TABLE 4 Cocaine pharmacokinetic parameters by gender in Example 1. C_(max) T_(max) AUC_(last) AUC_(inf) t_(1/2) (ng/mL) (h) (ng h/mL) (ng h/mL) (h) Male Female Male Female Male Female Male Female Male Female n 14 16 14 16 14 16 8 11 12 13 Mean 34.6 39.0 0.417 0.448 31.5 44.4 47.2 60.6 1.06 1.01 SD 17.6 17.2 0.322 0.366 12.7 23.7 13.1 29.0 0.346 0.365 CV 50.9 44.1 77.3 81.8 40.4 53.5 27.7 47.9 32.6 36.1 Median 31.6 37.0 0.333 0.333 28.5 32.4 46.2 57.6 0.966 1.01 Geometric 30.0 35.5 0.362 0.385 29.1 39.4 45.7 53.9 1.01 0.941 mean AUC_(inf): area under the concentration-time curve from time 0 to infinity; AUC_(last): area under the concentration-time curve from time 0 to the time of the last measurable concentration; C_(max): maximum concentration; CV: coefficient of variation; SD: standard deviation; t_(1/2): half-life; T_(max): time of maximum concentration.

Subject Age

AUC_(last) for cocaine was similar across the subject age range (22 years to 79 years) in Example 1 (see FIG. 5).

Subject Body Weight

There was a downward trend in AUC_(last) for cocaine with increasing body weight, the correlation (R²=0.0529) was not strong in Example 1 (see FIG. 6).

Subject BMI

There was no evidence for a change in AUC_(last) for cocaine with BMI (see FIG. 7).

Example 2

The primary objective of Example 2 was to evaluate the potential effect of renal impairment on the systemic pharmacokinetic parameters of acute intranasal treatment with the pharmaceutical composition. The secondary objective was to evaluate the safety and tolerability of acute intranasal treatment with the pharmaceutical composition in subjects with normal renal function and severe renal impairment.

Materials and Methods

Male and female subjects ≥18 years of age with either severe renal impairment (n=8), defined as an estimated glomerular filtration rate (eGFR) of 15-29 mL/min/1.73 m² or normal renal function (n=8), defined as an eGFR of ≥60 mL/min/1.73 m², and without a known allergy to ester-based anesthetics were enrolled in the study. Subjects were administered a pharmaceutical composition in the form of an aqueous solution comprising: 40 mg/mL cocaine hydrochloride, 1.25 mg/mL citric acid, 1.00 mg/mL sodium benzoate, a colorant (0.02 mg/mL D&C Yellow No. 10, 0.02 mg/mL FD&C Green No. 3), and 957.7 mg/mL water. The subjects were dosed with the pharmaceutical composition as follows: 4 mL of the pharmaceutical composition were poured into a standard medicine cup. Four (4) cottonoid pledgets (approximately 1.3 cm×4 cm) were soaked in the 4 mL of the pharmaceutical composition for 10 minutes and allowed to soak. Each pledget absorbed approximately 1 mL of solution. The drug-soaked pledgets were placed into the nasal cavity (2 per side) and up against the septum at time 0 and removed after 20 minutes.

Pharmacokinetic parameter blood samples were drawn at 0 hour (pre-dose), and post dose at: 7, 15, 20 (immediately after pledget removal), 30, 45, 60, 75, 90, and 105 min, and 2, 3, 4, 6, 8, 10, 12, 24, 28 and 32 h, based upon the beginning of dose application. Plasma was separated and stabilizer was added to prevent continued ester hydrolysis of cocaine in the samples. Total concentrations of cocaine and its major metabolites, BE and EME, and the active metabolite, norcocaine, were determined in all plasma samples using a validated LC-MS/MS method with an LLOQ of 0.1 ng/mL for cocaine and norcocaine, and 1.0 ng/mL for BE and EME. A 50-μL aliquot of each stabilized plasma sample was processed by liquid-liquid extraction. The compounds were detected and quantified by LC-MS/MS in positive ion mode on an MDS Sciex API 4000 equipped with a TURBOIONSPRAY® interface. Calibration curves were obtained by performing a linear regression (weighted 1/x²) on the calibration standards. Plasma pharmacokinetic parameters were analyzed using noncompartmental methods. Plasma pharmacokinetic parameters included AUC_(last), AUC_(inf), C_(max), T_(max), C_(last), T_(last), t_(1/2), CL/F (cocaine only), and % EXTRAP.

Plasma samples were analyzed for cocaine (LOQ, 0.1 ng/mL), benzoylecgonine (BE, LOQ, 1.0 ng/mL), ecgonine methyl ester (EME, LOQ, 1.0 ng/mL) and norcocaine (LOQ, 0.1 ng/mL) using the inVentiv Health Clinical Lab, Inc. Method TM.1668. Urine samples were analyzed for cocaine (LOQ, 0.1 ng/mL), benzoylecgonine (BE, LOQ, 1.0 ng/mL), and ecgonine methyl ester (EME, LOQ, 1.0 ng/mL).

Plasma and urine pharmacokinetic parameters for cocaine, BE, and EME were derived using non-compartmental methods. The specified PK parameters were not determined for norcocaine because plasma concentrations were below quantitation (<0.1 ng/mL) at all time points in most subjects. For the plasma analysis, C_(max), T_(max), C_(last), and T_(last) were determined by inspection. Concentrations reported as BQ (below quantitation) were assigned a value of zero if they were prior to T_(max), and were otherwise ignored. The area under the plasma concentration-time curve from time zero to T_(last) (AUC_(last)) was determined by trapezoidal integration. The AUC was extrapolated to infinity as: AUC_(inf)=AUC_(last)+(Cast/k), where k, the elimination rate constant was determined from the terminal log-linear concentration data using at least 3 time points. The half-life was calculated as t_(1/2)=ln 2/k. The CL/F for cocaine was determined as Dose/AUC_(inf). Values of AUC_(inf) for which the extrapolated portion of the AUC (% Extrap) was >30% were not used in the clearance calculations or summarized.

For the urine analysis of cocaine, BE, and EME, individual urinary recoveries for each analyte were determined over each collection interval as the product of the urine concentration times the urine volume. The total recoveries were determined as the sum of the recoveries over all the intervals. Total urinary recoveries were also expressed as the percentage of the administered dose, after correction for the molecular weight of each analyte. The renal clearances of cocaine, BE, and EME were determined as the urinary recovery (in μg) divided by the plasma AUC over the same time interval (the longest period for which both plasma and urine measurements were available).

Urine was collected prior to dosing and from 0-2, 2-4, 4-8, 8-12, 12-24, and 24-32 hours after the beginning of dose application. Urine concentrations of cocaine, BE, and EME were determined using a LC-MS/MS method with an LLOQ of 0.1 ng/mL for cocaine and 1.0 ng/mL for BE and EME. Testing methods used were consistent with those used by inVentiv Health Clinical Lab, Inc., Miami, Fla., U.S.A. Urinary pharmacokinetic parameters included total urinary recovery (μg), urinary recovery as a percentage of dose, and CLr.

Safety assessments, including monitoring adverse events (AEs), vital sign measurements, and laboratory tests were performed. A nasal exam was visually conducted pre-dose and at the end of the procedure to determine if irritation was present at the prospective application site.

A total of 8 subjects with normal renal function and 8 subjects with severe renal impairment were enrolled, and received the protocol-specified treatment with the pharmaceutical composition. All 16 subjects provided pharmacokinetic data. Pharmacokinetic parameters were compared between groups using analysis of variance (ANOVA) with renal status as a fixed effect. Geometric mean ratios with 90% confidence intervals (CI) were calculated to compare C_(max), AUC_(last), CLr, and CL/F for cocaine, and C_(max), AUC_(last), and CLr for each metabolite between subjects with normal renal function and for subjects with severe renal impairment.

Results

Demographic and baseline characteristics were similar in the normal renal function and severe renal impairment groups, except for eGFR. All of the subjects in the study were healthy adult male (75.0%) and female (25.0%) volunteers. The subjects ranged in age from 41 to 75 years (mean ages were 57.6 and 62.5 years in the normal renal function and severe renal impairment groups, respectively) and were black or white (87.5% and 12.5%, respectively). Mean eGFR was 85.25 mL/min/1.73 m² for the normal renal function group and 23.85 mL/min/1.73 m² for the severe renal impairment group. Mean body weight was 94.65 kg for the normal renal function group and 99.5 kg for the severe renal impairment group.

The pharmaceutical composition was safe and well tolerated in both subjects with normal renal function and subjects with severe renal impairment.

In subjects with normal renal function, cocaine appeared rapidly in the plasma following intranasal application of the pharmaceutical composition, with measurable levels in all subjects at the first time exponential manner after T_(max) throughout the remainder of the 32-hour study.

Following administration of the same pharmaceutical composition dose to subjects with severe renal impairment, a similar time course was observed, with rapid absorption followed by an apparently bi-exponential decline after T_(max). Plasma exposures in the severe renal impairment group were about 33% to 34% higher than those in normal subjects (see FIGS. 8 and 9).

In normal subjects, plasma concentrations of the metabolites, BE and EME, rose rapidly over the first few hours post-dose, then declined slowly over the remainder of the 32-hour sampling interval. Following administration of the same pharmaceutical composition dose to subjects with severe renal impairment, a similar pattern of rising BE and EME concentrations was observed during the first few hours after dosing. However, peak concentrations were generally at least 2-fold higher than those in normal subjects, and concentrations declined more slowly in subjects with severe renal impairment. Plasma concentrations of the active metabolite, norcocaine, were below the LLOQ (0.1 ng/mL) in all samples in all individuals, except for four samples in one subject in the renal impairment group, in which concentrations were barely above the LLOQ (0.101 to 0.115 ng/mL).

In subjects with normal renal function, cocaine appeared rapidly in the plasma following intranasal application of the pharmaceutical composition, with measurable levels in all subjects at the first time point, 7 minutes after the start of treatment. Plasma concentrations rose to reach a geometric mean C_(max) of 35.9 ng/mL at a median T_(max) of 30 minutes (10 minutes after pledget removal), and then declined in an apparently bi-exponential manner over the remainder of the 32-hour study. The apparent half-life of the terminal phase was 4.12 h, the AUC_(inf) was 80.5 ng*h/mL and the apparent clearance (CL/F) was 1774 L/h (geometric means). Following administration of the same pharmaceutical composition dose to subjects with severe renal impairment, a similar time course was observed, with rapid absorption followed by an apparently bi-exponential decline after T_(max). Plasma exposures in the severe renal impairment group were about 33% higher than those in normal subjects, with geometric mean C_(max) of 47.9 ng/mL and AUC_(inf) of 107.2 ng*h/mL. This was accompanied by a corresponding increase in the geometric mean half-life from 4.12 h in normal subjects to 5.42 h in severe renal impairment.

Cocaine plasma pharmacokinetic parameters in subjects with normal renal function and those with severe renal impairment are summarized below in Tables 5 and 6. The results of ANOVA (analysis of variance) of the pharmacokinetic parameters are presented in Table 7.

TABLE 5 Summary of cocaine pharmacokinetic parameters in subjects with normal renal function after a single intranasal dose of the anesthetic composition. Geometric Parameter unit n Mean SD CV mean Min Max Median C_(max) ng/mL 8 38.1 13.1 34.4 35.9 16.7 62.7 37.0 T_(max) h 8 0.583 0.378 64.8 0.518 0.333 1.500 0.500 C_(last) ng/mL 8 0.263 0.21 79.4 0.209 0.114 0.626 0.154 T_(last) h 8 22.5 9.304 41.4 20.6 12.0 32.0 24.0 AUC_(0→t) ng h/mL 8 83.5 26.4 31.7 78.7 34.29 109.9 91.6 AUC_(0→∞) ng h/mL 8 85.0 26.0 30.6 80.5 37.67 110.3 92.9 t_(1/2) h 8 5.00 3.301 66.0 4.12 2.06 10.67 3.89 CL/F L/h 8 1902 859 45.2 1774 1295 3793 1542 CL/F mL/min 8 31696 14325 45.2 29564 21584 63210 25697 C_(max), maximum concentration in plasma; T_(max), time at which C_(max) was observed; C_(last), last measurable concentration; T_(last), time at which C_(last) was observed; AUC_(0→t), Area under the concentration-time curve from time zero to T_(last); AUC_(0→∞), Area under the concentration-time curve from time zero to infinity; t_(1/2), half-life; CL/F, apparent clearance.

TABLE 6 Summary of cocaine pharmacokinetic parameters in subjects with severe renal impairment after a single intranasal dose of the pharmaceutical composition. Geometric Parameter unit n Mean SD CV mean Min Max Median C_(max) ng/mL 8 57.8 35.9 62.0 47.9 14.1 131.0 55.4 T_(max) h 8 0.448 0.147 32.9 0.429 0.333 0.750 0.417 C_(last) ng/mL 8 0.186 0.125 67.2 0.159 0.102 0.432 0.131 T_(last) h 8 28.0 7.09 25.3 26.9 12.0 32.0 32.0 AUC_(0→t) ng h/mL 8 118.8 58.1 48.9 105.8 43.0 221 109 AUC_(0→∞) ng h/mL 8 120.4 59.2 49.1 107.2 44.2 227 110 t_(1/2) h 8 6.02 2.30 38.3 5.42 1.53 8.65 6.39 CL/F L/h 8 1517 872 57.5 1333 630 3234 1304 CL/F mL/min 8 25291 14531 57.5 22211 10506 53905 21732 C_(max), maximum concentration in plasma; T_(max), time at which C_(max) was observed; C_(last), last measurable concentration; T_(last), time at which C_(last) was observed; AUC_(0→t), Area under the concentration-time curve from time zero to T_(last); AUC_(0→∞), Area under the concentration-time curve from time zero to infinity; t_(1/2), half-life; CL/F, apparent clearance.

TABLE 7 Summary of ANOVA comparing cocaine pharmacokinetic parameters in subjects with normal renal function and those with severe renal impairment after a single intranasal dose of the anesthetic composition. Geometric Least Comparison PK Renal Squares Test/ Ratio 90% parameter Function n Mean Reference (%) CI C_(max) Normal 8 35.9 Impaired/ 133.28 (81.39, (ng/mL) Impaired 8 47.9 Normal 218.24) AUC_(last) Normal 8 78.7 Impaired/ 134.46 (88.62, (ng · h/mL) Impaired 8 106 Normal 204.00) CL/F Normal 8 1774 Impaired/ 75.13 (50.02, (L/h) Impaired 8 1333 Normal 112.85) CLr Normal 8 1.61 Impaired/ 64.33 (32.67, (L/h) Impaired 7 1.04 Normal 126.67) AUC_(last): area under the plasma concentration-time curve from time 0 to the time of the last measurable concentration; CI: confidence interval; CL/F: apparent clearance; CLr: renal clearance; C_(max): maximum plasma concentration.

Cocaine plasma exposure, as indicated by geometric mean C_(max), AUC_(last), and AUC_(inf), values, was approximately 33% higher in subjects with renal impairment. CL/F was approximately 25% lower and CLr was approximately 36% lower in subjects with renal impairment than in normal subjects. Mean T_(max) and t_(1/2) values were similar in the two groups.

Plasma exposures of the metabolites, BE and EME, were higher in subjects with severe renal impairment than in those with normal renal function. Geometric mean C_(max) and AUC_(inf) values in the renal impairment group were approximately 2 times and 3 to 4 times higher, respectively, than those in subjects with normal renal function. Severe renal impairment resulted in a reduction in CLr for both BE and EME of approximately 76%.

In normal subjects, BE concentrations in plasma rose rapidly over the first few hours to reach a geometric mean C_(max) of 40.9 ng/mL at a median T_(max) of 2.5 h. Plasma BE then declined slowly over the remainder of the 32-hour study, with a half-life (8.429 h) that was approximately 2-fold longer than that of the parent drug. The geometric mean AUC_(inf) for BE was 639.2 ng*h/mL, nearly 8-fold higher than that of parent drug. Following administration of the same pharmaceutical composition dose to subjects with severe renal impairment a similar pattern of rising BE concentrations was observed during the first few hours after dosing. However, peak concentrations were more than 2-fold higher (geometric mean C_(max), 90.5 ng/mL) than those patients with normal renal function and median T_(max) was delayed until 6.0 h after dosing. Plasma BE declined slowly over the rest of the study, with 32-hour levels remaining at 41.3 ng/mL, compared to the 4 ng/mL observed in normal subjects. Valid assessment of AUC_(inf) values for BE could not be made, because % EXTRAP was greater than 30% in all renally-impaired subjects. The exposure to BE in severe renally impaired subjects (geometric mean AUC_(last), 2091 ng*h/mL) was more than 3.5-fold higher than in normal subjects (geometric mean AUC_(last), 589.5 ng*h/mL), while the half-life in severe renally impaired subjects (24.65 h) was increased nearly 3-fold compared to the half-life in normal subjects (8.429 h). These data suggest that the elimination of the BE metabolite of cocaine was notably decreased in severe renal impairment.

In normal subjects, EME concentrations in plasma rose over the first few hours to reach a geometric mean C_(max) of 5.8 ng/mL at a median T_(max) of 3.0 h, and then declined slowly over the remainder of the 32-hour study, with a half-life (5.02 h) slightly longer than that of the parent drug. The geometric mean AUC_(inf) for EME was 79.3 ng*h/mL, nearly identical to that of parent drug.

Following administration of the same pharmaceutical composition dose to subjects with severe renal impairment, a similar pattern of rising EME concentrations was observed during the first few hours after dosing. However, peak concentrations were nearly 2-fold higher (geometric mean C_(max), 10.3 ng/mL) than those in normal subjects. The geometric mean half-life of EME in severe renal impairment (13.16 h) was more than twice that observed in normal subjects (5.02 h), and the geometric mean AUC_(inf) (244.5 ng*h/mL) was approximately 3-fold higher than in normal subjects (79.3 ng*h/mL). These data suggest that severe renal impairment resulted in increased exposures to the EME metabolite of cocaine.

The cocaine metabolite BE plasma pharmacokinetic parameters in subjects with normal renal function and those with severe renal impairment are summarized below in Tables 8 and 9.

TABLE 8 Summary of BE pharmacokinetic parameters in subjects with normal renal function after a single intranasal dose of the pharmaceutical composition. Geometric Parameter unit n Mean SD CV mean Min Max Median C_(max) ng/mL 8 55.7 47.3 84.8 40.9 9.0 158.0 42.1 T_(max) h 8 3.22 1.92 59.7 2.75 1.25 6.00 2.50 C_(last) ng/mL 8 5.08 3.94 77.6 3.96 1.32 13.60 4.34 T_(last) h 8 32.0 0.00 0.00 32.0 32.0 32.0 32.0 AUC_(0→t) ng 8 762.1 614.5 80.6 589.5 167.4 2126 616 h/mL AUC_(0→∞) ng 8 823.8 658.8 80.0 639.2 186.1 2284 676 h/mL t_(1/2) h 8 8.47 0.900 10.6 8.429 7.37 9.79 8.32 C_(max), maximum concentration in plasma; T_(max), time at which C_(max) was observed; C_(last), last measurable concentration; T_(last), time at which C_(last) was observed; AUC_(0→t), Area under the concentration-time curve from time zero to T_(last); AUC_(0→∞), Area under the concentration-time curve from time zero to infinity; t_(1/2), half-life; a - AUC_(0→∞) not summarized, the extrapolated AUC exceeded 30% of the total AUC for all subjects in this group.

TABLE 9 Summary of BE pharmacokinetic parameters in subjects with severe renal impairment after a single intranasal dose of the pharmaceutical composition. Geometric Parameter unit n Mean SD CV mean Min Max Median C_(max) ng/mL 8 120.4 99.1 82.3 90.5 23.7 290.0 75.8 T_(max) h 8 6.625 2.774 41.9 6.13 3.00 12.0 6.00 C_(last) ng/mL 8 54.36 44.78 82.4 41.3 14.50 133.0 35.7 T_(last) h 8 32.0 0.00 0.00 32.0 32.0 32.0 32.0 AUC_(0→t) ng h/mL 8 2733.6 2190.7 80.1 2091 605.7 6242 1758 AUC_(0→∞) ng h/mL 0^(a) nd nd nd nd nd nd nd t_(1/2) h 8 24.97 4.355 17.4 24.65 19.85 31.62 24.0 C_(max), maximum concentration in plasma; T_(max), time at which C_(max) was observed; C_(last), last measurable concentration; T_(last), time at which C_(last) was observed; AUC_(0→t), Area under the concentration-time curve from time zero to T_(last); AUC_(0→∞), Area under the concentration-time curve from time zero to infinity; t_(1/2), half-life; ^(a)AUC_(0→∞) not summarized, the extrapolated AUC exceeded 30% of the total AUC for all subjects in this group.

The cocaine metabolite EME plasma pharmacokinetic parameters in subjects with normal renal function and those with severe renal impairment are summarized below in Tables 10 and 11.

TABLE 10 Summary of EME pharmacokinetic parameters in subjects with normal renal function after a single intranasal dose of the pharmaceutical composition. Geometric Parameter unit n Mean SD CV mean Min Max Median C_(max) ng/mL 8 7.5 5.7 75.7 5.8 1.8 19.2 5.8 T_(max) h 8 2.698 1.279 47.4 2.196 0.333 4.00 3.00 C_(last) ng/mL 8 1.583 0.552 34.9 1.505 1.070 2.58 1.42 T_(last) h 8 13.5 7.69 57.0 12.3 8.0 32.0 12.0 AUC_(0→t) ng h/mL 8 64.0 70.6 110.3 41.8 9.3 231 46.3 AUC_(0→∞) ng h/mL 6^(a) 94.5 73.3 77.6 79.3 44.4 241 66.8 t_(1/2) h 7 5.12 1.076 21.0 5.02 3.62 6.67 5.53 C_(max), maximum concentration in plasma; T_(max), time at which C_(max) was observed; C_(last), last measurable concentration; T_(last), time at which C_(last) was observed; AUC_(0→t), Area under the concentration-time curve from time zero to T_(last); AUC_(0→∞), Area under the concentration-time curve from time zero to infinity; t_(1/2), half-life; ^(a)AUC_(0→∞) not summarized, the extrapolated AUC exceeded 30% of the total AUC for all subjects in this group.

TABLE 11 Summary of EME pharmacokinetic parameters in subjects with severe renal impairment after a single intranasal dose of the pharmaceutical composition Geometric Parameter unit n Mean SD CV mean Min Max Median C_(max) ng/mL 8 11.9 5.9 49.9 10.3 3.2 20.5 11.5 T_(max) h 8 4.53 3.34 73.7 3.715 1.50 12.00 4.00 C_(last) ng/mL 8 2.46 1.440 58.5 2.218 1.51 5.85 1.93 T_(last) h 8 31.5 1.41 4.5 31.5 28.0 32.0 32.0 AUC_(0→t) ng h/mL 8 201.1 98.2 48.8 180.2 81.0 382 196 AUC_(0→∞) ng h/mL 7^(a) 267.5 130.0 48.6 244.5 143.9 527 242 t_(1/2) h 8 13.97 5.53 39.6 13.16 8.13 25.70 12.27 C_(max), maximum concentration in plasma; T_(max), time at which C_(max) was observed; C_(last), last measurable concentration; T_(last), time at which C_(last) was observed; AUC_(0→t), Area under the concentration-time curve from time zero to T_(last); AUC_(0→∞), Area under the concentration-time curve from time zero to infinity; t_(1/2), half-life; ^(a)AUC_(0→∞) not summarized, the extrapolated AUC exceeded 30% of the total AUC for all subjects in this group.

The parent drug, cocaine, and its primary metabolites, BE and EME, were all present in the urine following intranasal administration of pharmaceutical composition. The time course of cocaine recovery in the urine showed that the rate of urinary excretion was highest immediately after dosing, and then fell to lower levels beyond 12 hours. Urinary recovery curves were similar for normal and renally impaired subjects after 4 hours, but more cocaine was recovered in normal subjects during the first (0-2 h) collection period, suggesting a delay in excretion associated with renal impairment.

Urinary recovery of BE generally increased during the first 24 hours of the study, as expected from the longer residence of this metabolite in the body. In the severe renally impaired subjects, there was a tendency for lower BE recovery at earlier (2-12 h) time points and higher BE recovery at later (24-32 h) time points. This delay in excretion is consistent with the observation that severe renal impairment increased both plasma t_(1/2) and T_(max) of this metabolite.

The pattern of urinary recovery observed for the minor metabolite EME was similar for normal and severe renally impaired subjects. However, as observed for BE, the excretion of EME appeared to be delayed in the severe renal impairment group, with lower recoveries in the 2-12 h time frame, and higher recoveries in the 24-32 h time frame compared to normal subjects. Again, this delay is consistent with the increased plasma exposures observed for this metabolite.

In terms of 0-32 h urinary recoveries as a percent of the administered dose, the recovery of cocaine was, as expected, only a small fraction of the administered dose due to low topical bioavailability and systemic metabolism. The recovery of unchanged drug was 0.115% in normal subjects and 0.097% in severe renal impairment. The 0-32 h urinary recoveries for the two metabolites did not appear to differ between the two groups. (Table 12). Total (drug+metabolites) urinary recoveries were only slightly higher in severe renally impaired subjects (4.36±2.30%) compared to normal subjects (3.31±2.53%).

TABLE 12 Summary of urinary recovery showing 0 to 32 hour urinary recovery as % of administered dose of the pharmaceutical composition. Cocaine Benzoylecgonine Ecgonine Methyl Ester Total Urinary Recovery Normal Severe RI Normal Severe RI Normal Severe RI Normal Severe RI n 7 4 7 4 7 4 7 4 mean 0.115 0.097 2.029 2.744 1.167 1.519 3.31 4.36 SD 0.088 0.092 1.684 2.056 0.824 1.128 2.53 2.298 CV 76.27 94.90 83.03 74.94 70.65 74.21 76.4 52.7 median 0.089 0.063 1.089 1.988 0.952 1.177 2.20 4.00 geometric 0.086 0.072 1.546 2.294 0.954 1.255 2.625 3.899 mean Metabolite recoveries expressed as cocaine equivalents

Severe renal impairment appears to have reduced the renal clearances of all three analytes to some extent. For cocaine this effect was modest, with geometric mean clearance falling from 1.61 L/h (normal) to 1.04 L/h (renal impairment). The urinary clearance of BE fell from 3.61 L/h in normal subjects to 0.854 L/h in severe renally impaired subjects, while the renal clearance of EME fell from 18.1 L/h in normal subjects to 4.23 L/h in severe renally impaired subjects. These 4-fold reductions in renal clearance of the primary cocaine metabolites are consistent with the increases in plasma exposures and half-lives observed in this study, and support the conclusion that severe renal impairment is associated with substantial increases in exposure to the primary metabolites of cocaine observed after intranasal dosing.

TABLE 13 Summary of cocaine, BE, and EME urinary pharmacokinetic parameters in subjects with normal renal function and those with severe renal impairment after a single intranasal dose of the pharmaceutical composition. Renal Function Statistic Cocaine BE EME Total Urine Recovery as % of Dose^(a,b) Normal Mean 0.115 2.03 1.17 3.31 SD 0.088 1.68 0.824 2.53 CV % 76.3 83.0 70.7 76.4 Geomean 0.086 1.55 0.954 2.63 Impaired Mean 0.097 2.74 1.52 4.36 SD 0.092 2.06 1.13 2.30 CV % 94.9 74.9 74.2 52.7 Geomean 0.072 2.29 1.26 3.90 CLr (L/h)^(c) Normal Mean 2.00 3.77 19.1 SD 1.39 1.09 6.04 NA CV % 69.4 28.9 31.7 Geomean 1.61 3.61 18.1 Impaired Mean 1.22 0.919 4.95 SD 0.692 0.363 3.16 NA CV% 56.6 39.5 63.8 Geomean 1.04 0.854 4.23 ^(a)Includes subjects with complete urine collections over 32 h; metabolite recovery expressed as cocaine equivalents ^(b)n = 7 for normal renal function and n = 4 for severe renal impairment ^(c)n = 8 for normal renal function and n = 6 for severe renal impairment BE: benzoylecgonine; CLr: renal clearance; CV: coefficient of variation; EME: ecgonine methyl ester; Geomean: geometric mean; NA: not applicable; SD: standard deviation.

TABLE 14 Summary of urinary recovery for subjects with normal renal function over a period of 32 hours post administration of the pharmaceutical composition. 0-32 h Urinary Recovery (μg) Cocaine BE EME mean 164.2 2764 1095 SD 125.3 2295 773.5 CV 76.27 83.03 70.65 median 126.6 1483 892.8 geometric mean 122.8 2106 894.9

TABLE 15 Summary of urinary recovery for subjects with severe renal impairment over a period of 32 hours post administration of the pharmaceutical composition. 0-32 h Urinary Recovery (μg) Cocaine BE EME mean 138.5 3738 1425 SD 131.4 2802 1057.9 CV 94.90 74.94 74.21 median 89.8 2709 1104 geometric mean 102.7 3126 1177.8

TABLE 16 Summary of renal clearance for subjects with normal renal function post administration of the pharmaceutical composition. Cocaine BE EME Renal Clearance (L/h) mean 2.00 3.77 19.1 SD 1.39 1.09 6.04 CV 69.4 28.9 31.7 median 2.02 4.01 21.4 geometric mean 1.61 3.61 18.1 Renal Clearance (mL/min) mean 33.33 62.78 317.8 SD 23.1 18.16 100.6 CV 69.4 28.92 31.66 median 33.65 66.86 356.1 geometric mean 26.86 60.14 302.2

TABLE 17 Summary of renal clearance for subjects with severe renal impairment post administration of the anesthetic composition. Cocaine BE EME Renal Clearance (L/h) mean 1.22 0.919 4.95 SD 0.692 0.363 3.16 CV 56.6 39.5 63.8 median 1.18 0.824 4.05 geometric mean 1.04 0.854 4.23 Renal Clearance (mL/min) mean 20.37 15.3 82.5 SD 11.5 6.05 52.7 CV 56.62 39.5 63.8 median 19.59 13.7 67.6 geometric mean 17.28 14.2 70.6

Effect of Renal Impairment

Cocaine and its principal metabolites, BE and EME, were observed in both plasma and urine after a single intranasal exposure to the pharmaceutical composition, equivalent to 160 mg of cocaine hydrochloride, in subjects with normal renal function (eGFR≥60 mL/min/1.73 m²) and severe renal impairment (eGFR 15-29 mL/min/1.73 m²). Norcocaine was not measurable in the plasma of most subjects. Severe renal impairment was associated with a 76% decrease in renal clearance of BE and EME, resulting in notable increases in plasma exposure (C_(max) and AUC) to these metabolites compared to normal subjects.

In humans, cocaine is eliminated predominantly by metabolism, with little excreted unchanged in the urine. Only 1% to 10% of a dose of cocaine is eliminated unmetabolized in urine. Consistent with this low urinary recovery, cocaine CLr is less than 2% of CL. CLr values are less than 40% of human glomerular filtration rate (“GFR”) (125 mL/min).

Intranasal administration of the pharmaceutical composition was safe and well tolerated in both subjects with normal renal function and subjects with severe renal impairment. The geometric mean cocaine C_(max) value in subjects with severe renal impairment (47.9 ng/mL) was well below these values, indicating that the risk of cardiac repolarization effects would be negligible in renally impaired individuals. The minimal effect of renal impairment on exposure of the active parent drug, cocaine, coupled with the low risk of cardiac effects expected in this group, suggests that dose adjustment of pharmaceutical composition should not be required in subjects with reduced renal function.

Example 3

The primary objective of Example 3 was to evaluate the potential effect of hepatic impairment on the systemic pharmacokinetic parameters of the pharmaceutical composition after single dose intranasal administration. The secondary objective was to evaluate the safety and tolerability of the pharmaceutical composition in subjects with normal hepatic function and hepatic impairment.

Materials and Methods

Twelve male and female subjects ≥18 years of age with either Child-Pugh Grade B (n=9) or Grade C (n=3) hepatic impairment or normal hepatic function (n=12), and without a known allergy to ester-based anesthetics were enrolled in the study. Subjects were dosed with pharmaceutical composition in the form of an aqueous solution comprising 40 mg/mL cocaine hydrochloride, 1.25 mg/mL citric acid, 1.00 mg/mL sodium benzoate, a colorant (0.02 mg/mL D&C Yellow No. 10, 0.02 mg/mL FD&C Green No. 3), and 957.7 mg/mL water. The subjects were dosed as follows: four mL (4 mL) of the pharmaceutical composition (containing approximately 160 mg of cocaine hydrochloride) were poured into a standard medicine cup. Four (4) cottonoid pledgets (approximately 1.3 cm×4 cm) were soaked in the 4 mL of the solution for 10 minutes and allowed to soak. Each pledget absorbed approximately 1 mL of solution. The drug-soaked pledgets were placed into the nasal cavity (2 per side) and against the septum of each subject at time 0 and removed after 20 minutes.

Pharmacokinetic blood samples were drawn at 0 hour (pre-dose), and post dose at: 7, 15, 20 (immediately after pledget removal), 30, 45, 60, 75, 90, and 105 min, and 2, 3, 4, 6, 8, 10, 12, 24, 28, and 32 h, based upon the beginning of dose application. Plasma was separated and stabilizer was added to prevent continued ester hydrolysis of cocaine in the samples. Total concentrations of cocaine and it major metabolites, BE and EME, and the active metabolite, norcocaine, were determined in all plasma samples using a validated LC-MS/MS method with an LLOQ of 0.1 ng/mL for cocaine and norcocaine, and 1.0 ng/mL for BE and EME. A 50-μL aliquot of each stabilized plasma sample was processed by liquid-liquid extraction. The compounds were detected and quantified by LC-MS/MS in positive ion mode on an MDS Sciex API 4000 equipped with a TURBOIONSPRAY® interface. Calibration curves were obtained by performing a linear regression (weighted 1/x²) on the calibration standards. Plasma pharmacokinetic parameters were analyzed using noncompartmental methods. Plasma pharmacokinetic parameters included AUC_(last), AUC_(inf), C_(max), T_(max), C_(last), T_(last), t_(1/2), CL/F (cocaine only), and % EXTRAP.

Urine was collected prior to dosing and from 0-2, 2-4, 4-8, 8-12, 12-24, and 24-32 hours after beginning of dose application. Urine concentrations of cocaine, BE, and EME were determined using a validated LC-MS/MS method with an LLOQ of 0.1 ng/mL for cocaine and 1.0 ng/mL for BE and EME. Urinary pharmacokinetic parameters included total urinary recovery (μg), urinary recovery as a percentage of dose, and CLr.

Safety assessments, including monitoring AEs, vital sign measurements, and laboratory tests were performed. A nasal exam was visually conducted pre-dose and at the end of the study to determine if irritation was present at the prospective application site.

Pharmacokinetic parameters were compared between groups using ANOVA with hepatic function (Grade B or Grade C impaired vs. normal) as a fixed effect. Geometric mean ratios with 90% confidence intervals were calculated to compare C_(max), AUC_(last), and CL/F for cocaine, and C_(max) and AUC_(last) for each metabolite between subjects with normal hepatic function and subjects with hepatic impairment.

Results

Demographic and baseline characteristics were similar in the normal hepatic function, Grade B hepatic impairment, and Grade C hepatic impairment groups. All of the subjects in the study were healthy adult male (83.3%) and female (16.7%) volunteers. The subjects ranged in age from 27 to 74 years (overall mean, 51.7 years), were white or black (83.3% and 16.7%, respectively), and had an overall mean body weight of 91.25 kg.

The pharmaceutical composition was observed as safe and well tolerated in subjects with normal hepatic function, as well as subjects with Grade B and Grade C hepatic impairment.

In subjects with normal hepatic function, cocaine appeared rapidly in the plasma following intranasal application of the pharmaceutical composition, (reaching T_(max) at approximately 0.5 hours) with measurable levels in all subjects at the first time point (7 min) after the start of treatment. Plasma concentrations declined in an apparently bi-exponential manner after T_(max) throughout the remainder of the 32-hour study.

Following administration of the same pharmaceutical composition dose to subjects with hepatic impairment, the time course of plasma cocaine appeared somewhat delayed compared to normal subjects, with a later T_(max), a broader peak, and slower decline during the initial 12 hours after dosing. After T_(max), plasma cocaine exposures in the hepatic impairment group were about 2.5 times higher than those patients with normal hepatic function (FIGS. 10 and 11).

In normal subjects, plasma concentrations of the metabolites BE and EME rose rapidly over the first few hours post-dose, then declined slowly over the remainder of the 32-hour sampling interval. Following administration of the same pharmaceutical composition dose to subjects with hepatic impairment, BE and EME concentrations rose more slowly, with a delayed T_(max), and exhibited a broader peak than observed in subjects with normal hepatic function. Peak concentrations were 1.5 to 2 times higher than those in normal subjects, and concentrations declined at a similar rate (EME) or more slowly (BE) in subjects with hepatic impairment. Plasma concentrations of the active metabolite, norcocaine, were not measurable (LLOQ=0.1 ng/mL) in plasma after pharmaceutical composition dosing in any of the subjects with normal hepatic function, or in 8 of the 12 subjects with hepatic impairment. Norcocaine was detected at low levels (≤0.31 ng/mL), within 3 times the LLOQ, at multiple time points in three Grade B impaired subjects, and at a single time point in one Grade B subject (0.354 ng/mL at 7 min).

Hepatic impairment had little to no effect on the C_(max) of cocaine; geometric means were 5% higher (56% higher with the outlier included) and 32% lower in Grade B and Grade C hepatic impairment, respectively, and 90% confidence intervals (Cl) on geometric mean ratios (GMR) encompassed 100% for both hepatic impairment groups. The geometric mean C_(max) value across all hepatically impaired individuals was 7% lower (27% higher with the outlier included) than that in subjects with normal hepatic function. The apparent clearance of cocaine was correspondingly reduced in hepatically impaired subjects, with GMR (90% CI) of 36.25% (22.78-57.68%) for Grade B and 55.28% (28.80-106.12%) for Grade C impairment. The geometric mean half-life for cocaine was 6.62 h in normal subjects and 4.99 h in hepatic impairment.

Cocaine plasma pharmacokinetic parameters in subjects with normal hepatic function and those with hepatic impairment are summarized in Tables 18 and 19. The results of ANOVA are presented in Table 20.

TABLE 18 Summary of cocaine pharmacokinetic parameters in subjects with normal hepatic function after administration of a single intranasal dose of the pharmaceutical composition. Geometric Parameter unit n Mean SD CV mean Min Max Median Cmax ng/mL 12 50.6 21.0 41.5 44.2 7.64 75.2 53.6 Tmax h 12 0.431 0.0858 19.9 0.422 0.333 0.500 0.500 Clast ng/mL 12 0.210 0.107 51.0 0.188 0.102 0.405 0.160 Tlast h 12 26.0 7.34 28.2 24.7 12.0 32.0 28.0 AUC_(0-t) ng h/mL 12 92.8 55.3 59.5 79.2 20.0 235 82.4 AUC_(0-∞) ng h/mL 12 95.3 54.7 57.4 82.4 21.7 237 83.3 t_(1/2) h 12 8.11 5.55 68.4 6.62 1.84 22.5 6.93 CL/F L/h 12 2066 1538 74.4 1735 604 6588 1744 CL/F mL/min 12 34438 25637 74.4 28911 10064 109805 29065

TABLE 19 Summary of cocaine pharmacokinetic parameters in subjects with with hepatic impairment after a single intranasal dose of the anesthetic composition. Geometric Parameter unit n Mean SD CV mean Min Max Median Cmax ng/mL 11 50.7 34.5 68.0 41.2 17.1 119 42.6 Tmax h 11 1.09 0.784 72.1 0.828 0.117 3.00 0.750 Clast ng/mL 11 0.393 0.469 119 0.270 0.115 1.73 0.211 Tlast h 11 31.6 1.21 3.81 31.6 28.0 32.0 32.0 AUC_(0-t) ng h/mL 11 223 138 61.8 189 89.5 523 176 AUC_(0-∞) ng h/mL 11 227 139 61.1 192 90.9 528 177 t_(1/2) h 11 5.42 2.17 40.0 4.94 1.46 9.86 5.63 CL/F L/h 11 867 477 55.0 743 271 1571 808 CL/F mL/min 11 14446 7948 55.0 12377 4512 26182 13468

The geometric mean C_(max) value across all hepatically impaired individuals was 7% lower (27% higher with the outlier included) than that in subjects with normal hepatic function (Table 20). Overall exposure of cocaine was elevated somewhat in hepatic impairment. Plasma cocaine AUC_(last) was 2.8-times higher in Grade B impaired subjects and 1.8-times higher in Grade C impaired subjects compared to normal subjects. Cocaine CL/F was correspondingly reduced, by 64% and 45% in subjects with Grade B and Grade C hepatic impairment, respectively.

A statistical analysis was conducted to evaluate the potential effects of hepatic impairment on the primary pharmacokinetic endpoints of Example 3. Analysis of Variance (ANOVA) on hepatic function was carried out on the following natural log-transformed PK parameters:

-   -   AUC_(last) and C_(max) for cocaine, BE, and EME using hepatic         status as a fixed effect     -   CL/F for cocaine using hepatic status as a fixed effect.

GMR with 90% confidence intervals were calculated comparing each of the above PK parameters between hepatically impaired subjects (Grade B or C) and normal subjects, based on these ANOVA models.

TABLE 20 Summary of ANOVA comparing cocaine pharmacokinetic parameters in subjects with normal hepatic function and those with Grade B or Grade C hepatic impairment after a single intranasal dose of the pharmaceutical composition. Geometric Least PK Hepatic Squares Comparison parameter Function n Mean Test/Reference Ratio (%) 90% CI C_(max) Normal 12  44.2 — — — (ng/mL) Grade B^(a) 8 46.4 Grade B/Normal 104.89 (61.07, 180.17) Grade C 3 30.1 Grade C/Normal 68.13 (34.30, 135.33) AUC_(last) Normal 12  79.2 — — — (ng · h/mL) Grade B 9 225 Grade B/Normal 284.54 (176.53, 458.63)  Grade C 3 142 Grade C/Normal 179.88 (91.85, 352.27) CL/F Normal 12  1735 — — — (L/h) Grade B 9 629 Grade B/Normal 36.25 (22.78, 57.68)  Grade C 3 959 Grade C/Normal 55.28 (28.80, 106.12) ^(a)Excludes one subject with anomalous concentration value at 7 minutes; AUC_(last); area under the plasma concentration-time curve from time 0 to the time of the last measurable concentration; CI; confidence interval; CL/F: apparent clearance; C_(max): maximum plasma concentration.

Overall plasma exposures of the metabolites BE and EME were higher in subjects with hepatic impairment than in those with normal hepatic function. In subjects with Grade B hepatic impairment, geometric mean C_(max) values for the metabolites were less than 2 times higher, and AUC_(last) values were approximately 2.4-times higher, than in subjects with normal hepatic function. In the 3 Grade C hepatic impairment subjects, AUC_(last) values were 2.2 times higher (EME) or not appreciably changed (BE; 12% increased) compared to subjects with normal hepatic function. There was no appreciable change (12 to 18% reduction) in BE or EME C_(max) in Grade C hepatic impairment compared to normal subjects.

The cocaine metabolite BE plasma pharmacokinetic parameters in subjects with normal renal function and those with severe renal impairment are summarized below in Tables 21 and 22.

TABLE 21 Summary of BE pharmacokinetic parameters in subjects with normal hepatic function after administration of a single intranasal dose of the pharmaceutical composition. Geometric Parameter unit n Mean SD CV mean Min Max Median Cmax ng/mL 12 57.5 45.2 78.7 43.7 7.03 171 35.5 Tmax h 12 2.38 1.92 81.0 1.96 1.00 8.00 1.63 Clast ng/mL 12 6.17 8.13 132 4.33 2.02 31.6 3.71 Tlast h 12 32.0 0.00 0.00 32.0 32.0 32.0 32.0 AUC_(0-t) ng h/mL 12 784 736 94.0 603 144 2969 523 AUC_(0-∞) ng h/mL 12 869 855 98.3 667 182 3446 568 t_(1/2) h 12 9.16 1.86 20.3 9.00 6.64 13.1 8.91

TABLE 22 Summary of BE pharmacokinetic parameters in subjects with hepatic impairment after administration of a single intranasal dose of the pharmaceutical composition. Geometric Parameter unit n Mean SD CV mean Min Max Median Cmax ng/mL 12 81.2 61.7 75.9 67.1 27.4 248 67.8 Tmax h 12 7.50 2.97 39.6 6.95 4.00 12.0 7.00 Clast ng/mL 12 17.6 10.8 61.6 14.3 3.33 42.6 16.6 Tlast h 12 32.0 0.00 0.00 32.0 32.0 32.0 32.0 AUC_(0-t) ng h/mL 12 1402 790 56.3 1235 606 3356 1190 AUC_(0-∞) ng h/mL  8 1724 945 54.8 1513 647 3532 1448 t_(1/2) h 12 14.0 7.60 54.2 12.3 6.65 31.0 12.1

EME plasma pharmacokinetic parameters in subjects with normal hepatic function and those with severe hepatic impairment are summarized below in Tables 23 and 24.

TABLE 23 Summary of EME pharmacokinetic parameters in subjects with normal hepatic function after administration of a single intranasal dose of the pharmaceutical composition. Geometric Parameter unit n Mean SD CV mean Min Max Median Cmax ng/mL 11 10.0 6.30 62.9 8.75 3.83 26.8 7.81 Tmax h 11 1.45 0.650 44.7 1.33 0.500 3.00 1.25 Clast ng/mL 11 1.85 0.904 49.0 1.67 1.00 3.72 1.60 Tlast h 11 16.5 6.82 41.2 15.4 10.0 28.0 12.0 AUC_(0-t) ng h/mL 11 72.9 50.0 68.5 61.2 24.5 198 59.1 AUC_(0-∞) ng h/mL  9 89.6 56.6 63.2 76.1 31.5 212 72.9 t_(1/2) h 11 6.27 2.03 32.4 5.99 4.16 9.97 5.69

TABLE 24 Summary of EME pharmacokinetic parameters in subjects with hepatic impairment after administration of a single intranasal dose of the pharmaceutical composition. Geometric Parameter unit n Mean SD CV mean Min Max Median Cmax ng/mL 12 16.1 14.9 92.5 11.3 2.57 52.7 9.11 Tmax h 12 3.84 1.93 50.1 2.90 0.117 6.00 4.00 Clast ng/mL 12 1.65 0.542 32.9 1.57 1.02 2.97 1.67 Tlast h 12 27.7 7.52 27.2 26.3 12.0 32.0 32.0 AUC_(0-t) ng h/mL 12 185 130 70.3 146 25.6 505 140 AUC_(0-∞) ng h/mL 10 233 118 50.8 212 127 517 185 t_(1/2) h 10 9.26 3.64 39.3 8.67 5.44 15.7 8.30

Norcocaine plasma pharmacokinetic parameters in subjects with normal hepatic function could not be determined because the concentrations of norcocaine were below the limit of quantitation (0.1 ng/mL) in all subjects with normal hepatic function at all study time points. Norcocaine plasma pharmacokinetic parameters in subjects with severe hepatic impairment are summarized below in Table 25.

TABLE 25 Summary of norcocaine pharmacokinetic parameters in subjects with hepatic impairment after administration of a single intranasal dose of the pharmaceutical composition. Geometric Parameter unit n Mean SD CV mean Min Max Median Cmax ng/mL 3 0.227 0.0751 33.1 0.219 0.160 0.308 0.212 Tmax h 3 1.50 0.00 0.00 1.50 1.50 1.50 1.50 Clast ng/mL 3 0.127 0.0225 17.7 0.126 0.105 0.150 0.126 Tlast h 3 6.33 4.93 77.9 5.24 3.00 12.0 4.00 AUC_(0-t) ng h/mL 3 0.950 0.735 77.4 0.753 0.309 1.75 0.788 AUC_(0-∞) ng h/mL 0 nd nd nd nd nd nd nd t_(1/2) h 2 6.23 5.12 82.2 5.07 2.61 9.85 6.23 nd - could not be determined; plasma norcocaine concentrations were below the limit of quantitation (0.1 ng/mL) at all time points in 8 of the 12 subjects with hepatic impairment.

Cocaine, BE, and EME were all excreted into urine following intranasal administration of pharmaceutical composition. Hepatic impairment increased the geometric mean urinary recovery of the BE and EME metabolites by approximately 2-fold compared to normal subjects, but had little effect on geometric mean cocaine recovery. These increased recoveries were not accompanied by a proportional increase in CLr of the metabolites; geometric mean CLr values for BE and EME were in fact slightly lower in hepatic impairment and were highly variable in both groups.

The parent drug, cocaine, and its primary metabolites, BE and EME, were all present in the urine following intranasal administration of the pharmaceutical composition. The time course of cocaine recovery in the urine of normal subjects showed that the rate of urinary excretion was highest immediately after dosing, and then fell at later time points. In hepatically impaired subjects, cocaine urinary recovery rose over the first 8 hours, and then fell to levels similar to those in normal subjects from 12 to 32 hours, suggesting a delay in cocaine excretion associated with hepatic impairment.

Urinary recovery of BE generally increased during the first 24 hours of the study, as expected from the longer residence of this metabolite in the body. In the hepatic impairment subjects, higher BE recovery was observed, especially in the 12 and 24 h collections. This pattern resulted in an approximately 2-fold increase in urinary recovery of BE in the hepatically impaired subjects.

The pattern of urinary recovery observed for EME demonstrated greater urinary recovery of EME in the 8 to 32 h collections in subjects with hepatic impairment compared to normal subjects. This resulted in a 2.2-fold increase in urinary recovery of EME in the hepatically impaired subjects.

In terms of 0-32 h urinary recoveries as a percent of the administered dose, the recovery of cocaine was, as expected, only a small fraction of the administered dose due to low topical bioavailability and systemic metabolism. The recovery of unchanged drug was 0.057% in normal subjects and 0.071% in hepatic impairment. The 0-32 h urinary recoveries increased by about 2-fold for BE, and 2.5-fold for EME in the hepatic impairment group compared to normal subjects. Total (drug+metabolites) urinary recoveries were 2.92±1.54% in normal subjects and 6.96±5.77% in hepatic impairment subjects, an increase of more than 2-fold resulting from hepatic impairment.

Hepatic impairment had little to no effect on cocaine recovery, but increased the urinary recoveries of the BE and EME metabolites by roughly 2-fold. These increased recoveries were not accompanied by a proportional increase in renal clearance. Rather, renal clearance for the metabolites was slightly lower (less than 40%) in hepatic impairment and was highly variable in both groups, with individual values overlapping considerably between subjects with normal or impaired hepatic function. The increased urinary metabolite recoveries were accompanied by increased plasma exposures in hepatic impairment. These changes suggest that increased exposures to BE and EME were mainly due to a reduction in hepatic elimination pathways for these metabolites in subjects with hepatic impairment.

Although urinary recovery of cocaine was nearly unchanged, both the renal and apparent plasma clearances were reduced in the presence of hepatic impairment, leading to increased systemic exposures to the parent drug. It is notable that the plasma half-life of cocaine was not increased in subjects with hepatic impairment.

TABLE 26 Summary of cocaine, BE, and EME urinary pharmacokinetic parameters in subjects with normal hepatic function and those with hepatic impairment after administration of a single intranasal dose of the pharmaceutical composition. Hepatic Function Statistic Cocaine BE EME Total Urine Recovery as % of Dose^(a,b) Normal Mean 0.072 1.73 1.12 2.92 SD 0.045 1.00 0.558 1.54 CV % 62.5 57.7 49.9 52.6 Geomean 0.057 1.42 0.93 2.46 Impaired Mean 0.143 3.30 3.51 6.96 SD 0.130 2.14 3.67 5.77 CV % 91.1 64.8 105 8.29 Geomean 0.071 2.74 2.43 5.40 CLr (L/h)^(c) Normal Mean 1.79 4.30 17.2^(d) NA SD 1.64 2.07 11.5 CV% 91.9 48.3 66.8 Geomean 1.17 3.96 14.6 Impaired Mean 0.997 2.90 10.9 NA SD 92.3 47.9 41.1 CV% 0.921 1.39 4.47 Geomean 0.468 2.59 10.2

TABLE 27 Summary of urinary recovery for subjects with normal hepatic function over a period of 32 hours post administration of the pharmaceutical composition. 0-32 h Urinary Recovery (μg) Cocaine BE EME mean 102.25 2359.75 1048.23 SD 63.91 1360.71 523.42 CV 62.51 57.66 49.93 median 108.1 2098.9 1164.3 geometric mean 81.5 1928.3 875.2

TABLE 28 Summary of urinary recovery for subjects with hepatic impairment over a period of 32 hours post administration of the pharmaceutical composition. 0-32 h Urinary Recovery (pg) Cocaine BE EME mean 204 4500 3294 SD 185.7 2916 3442 CV 91.14 64.81 104.48 median 193.5 3283.7 2249.7 geometric mean 101.4 3735.6 2278.1

TABLE 29 Summary of renal clearance for subjects with normal hepatic function post administration of the pharmaceutical composition. Cocaine BE EME Renal Clearance (L/h) mean 1.790 4.2951 71.585 SD 1.644 2.073 34.550 CV 91.87 48.26 48.26 median 1.322 3.494 58.237 geometric mean 1.172 3.957 65.948 Renal Clearance (mL/min) mean 29.827 71.585 286.128 SD 27.403 34.550 191.157 CV 91.87 48.26 66.81 median 22.027 58.237 219.782 geometric mean 19.530 65.948 243.011

TABLE 30 Summary of renal clearance for subjects with hepatic impairment post administration of the pharmaceutical composition. Cocaine BE EME Renal Clearance (L/h) mean 0.9970 2.8964 10.8740 SD 0.9207 1.3875 4.4662 CV 92.3 47.9 41.1 median 0.9360 2.8680 9.6551 geometric mean 0.4676 2.5866 10.1852 Renal Clearance (mL/min) mean 16.62 48.27 181.23 SD 15.34 23.12 74.44 CV 92.3 47.9 41.1 median 15.60 47.80 160.92 geometric mean 7.79 43.11 169.75

Effects of Hepatic Impairment

Cocaine and its principal metabolites, BE and EME, were observed in both plasma and urine after a single intranasal exposure to the pharmaceutical composition, equivalent to 160 mg of cocaine hydrochloride, in subjects with normal hepatic function and hepatic impairment (Child-Pugh Grades B and C). Norcocaine was not measurable in the plasma of normal subjects or in 8 of 12 hepatically impaired subjects. Hepatic impairment had a minimal effect on the C_(max) of cocaine. Compared to subjects with normal hepatic function, a less than 2-fold increase in geometric mean C_(max) was observed for BE and EME in Grade B hepatic impairment, with no appreciable change in BE and EME C_(max) observed in Grade C hepatic impairment. In subjects with Grade B hepatic impairment, AUC values for cocaine, BE, and EME were 2.4 to 2.8 times higher than in subjects with normal hepatic function. The effects of hepatic impairment on cocaine, BE, and EME were less marked in the 3 subjects with Grade C impairment than in the 9 subjects with Grade B hepatic impairment. Increased overall plasma exposures of cocaine (AUC) were consistent with observed decreases in both CL/F and CLr.

There was a minimal effect of hepatic impairment on cocaine C_(max) and an increase in AUC. This is consistent with the fact that early systemic concentrations are driven by rapid uptake via the nasal mucosa, which completely bypasses the liver, while prolonged elevations in cocaine plasma concentrations after T_(max) may be due to reduced hepatic elimination of drug circulating in plasma. In addition, the increases in plasma exposure of BE and EME observed in subjects with hepatic impairment were accompanied by elevated urinary recovery of the metabolites, resulting in a minimal change in CLr for these compounds. This suggests that the enhanced systemic levels of the metabolites may be due to reduced liver elimination in subjects with hepatic impairment, and is consistent with observations that BE and EME are formed in part by hepatic carboxylesterases.

The minimal effect of hepatic impairment on cocaine C_(max), coupled with the low risk of cardiac effects expected in this group, suggests that dose adjustment of pharmaceutical composition should not be required in subjects with reduced hepatic function. However, based on the sustained higher exposure of cocaine in the post-absorptive phase and the potential for a cumulative increase in systemic concentrations, a second dose of pharmaceutical composition should not be administered to subjects with hepatic impairment within 24 hours of the initial dose.

Example 4

The objective of Example 4 was to assess the efficacy and safety of the pharmaceutical composition after topical intranasal administration of a single dose in adult patients undergoing intranasal procedures.

Example 4 was a randomized, double-blind, multicenter, placebo- and dose-controlled, single-dose study in 648 adult patients undergoing a diagnostic or surgical procedure on or through the mucous membranes of one or both of the nasal cavities.

The objective of Example 4 was to evaluate the efficacy of pharmaceutical composition in the form of topical aqueous solutions including, by weight, 4% and 8% cocaine hydrochloride as anesthetics for diagnostic procedures and surgeries on or through the mucous membranes of the nasal cavities (e.g., nasal/sinus endoscopy, sinusotomy, fracture nasal turbunate[s], lysis intranasal synechia, insertion of nasal septal prosthesis, biopsy intranasal, excision of nasal polyps, excision turbinate[s], removal of foreign body intranasal, septoplasty, and sinus debridement). The topical aqueous solutions used in this example were: 40 mg/mL cocaine hydrochloride, 1.25 mg/mL citric acid, 1.00 mg/mL sodium benzoate, a colorant (0.02 mg/mL D&C Yellow No. 10, 0.02 mg/mL FD&C Green No. 3), and 957.7 mg/mL water, or 80 mg/mL cocaine hydrochloride, 1.25 mg/mL citric acid, 1.00 mg/mL sodium benzoate, a colorant (0.02 mg/mL D&C Yellow No. 10, 0.02 mg/mL FD&C Green No. 3), and 917.7 mg/mL water.

Example 4 consisted of a screening period performed within 14 days of a 1-day diagnostic procedure or surgery, a treatment period performed on the day of the diagnostic procedure or surgery (Day 1), and a follow-up visit (Day 8). Male and female patients ≥18 years of age with the need for a diagnostic procedure or surgery on or through the nasal mucous membranes of either one or both nostrils, and who had the ability to feel pain in the anterior nasal septum and to clearly communicate the pain sensation, were enrolled in this study. Patients were randomized in a 1:3:3 ratio to placebo, 4% pharmaceutical composition (40 mg/mL cocaine hydrochloride), or 8% pharmaceutical composition (80 mg/mL cocaine hydrochloride), respectively. Patients did not receive general anesthesia.

Immediately following drug treatment, the nasal mucous membranes were assessed for local analgesia using the von Frey filament test and a visual numeric rating scale (VNRS) for patient self-reporting of pain intensity (0=no pain and 10=worst possible pain) (FIG. 12).

The investigator chose the nostril for pre-procedural testing based upon the scheduled procedure. Each patient was asked to close his/her eyes to prevent any visual clues. A large von Frey filament (6.10; 100 g) was applied to the nasal ala, vestibule, nasal hairs, and anterior septum to help the subject discriminate between these structures. The nasal ala was gently retracted laterally with a blunt-ended, single-pronged retractor to provide easy access to the nasal septum during measurements. The filament (6.10; 100 g) was pushed, at a perpendicular angle, against the anterior nasal septum until it bent, at which time a standardized force was applied to the anterior nasal septum. The subject was then asked to rate the pain experienced using the VNRS. The investigator counseled the patient that pain and not pressure was being measured and that pressure was not to be reported as pain.

Following pre-procedural von Frey filament testing, the study blind was broken for placebo versus pharmaceutical composition to ensure that placebo-treated patients with a VNRS score of 0 did not undergo the diagnostic or surgical procedure without anesthesia. The study blind was maintained for the dose of pharmaceutical composition (4% or 8%).

Efficacy Endpoints and Analyses

The primary efficacy endpoint was analgesic success. A subject was considered an analgesic success if both of the following criteria were met:

-   -   Had a score of 0 on the VNRS based on the von Frey filament test         prior to the diagnostic procedure or surgery.     -   Had no need for further medication (with the exception of         antibiotics or cardiac medications) during the diagnostic         procedure or surgery as determined by the investigator/physician         based upon his/her clinical impressions of the presence of pain         or excessive bleeding.

Patients who had a VNRS score >0 immediately following study drug treatment or who needed additional medication (other than antibiotics or cardiac medications) during the procedure were considered treatment failures.

The percentage of patients who achieved analgesic success in the intent-to-treat (ITT) population, defined as all patients who were randomized and received study drug, was compared between the placebo and the pharmaceutical composition test groups using a two-tailed Fisher's Exact Test at an alpha 0.05 level of significance. The primary comparison for analgesic success was between the 4% pharmaceutical composition and placebo groups. The proportion of analgesic success was also tested for the 8% pharmaceutical composition versus placebo.

To determine whether analgesic success was consistent across subgroups, the following subgroups were evaluated:

-   -   Sex (male and female)     -   Race (white, black, and all other races pooled)     -   Age (≥44 years [median] and <44 years)     -   Weight (≥80 kg [median] and <80 kg).

All subgroup analyses were performed using the ITT population defined as all patients who were considered an analgesic success in that they achieved a VNRS score of 0=no pain, and had no need for further medication (with the exception of antibiotics or cardiac medications) during the diagnostic procedure or surgery as determined by the investigator/physician based upon his/her clinical impressions of the presence of pain or excessive bleeding.

Demographics and Baseline Characteristics

The placebo, 4% cocaine hydrochloride solution, and 8% cocaine hydrochloride solution groups were similar with respect to age, sex, race, height, and weight (Table 31). Most of the patients were female (60.5%) and white (78.9%) with a mean age of 44.1 years (range, 17 to 86 years).

TABLE 31 Demographics and baseline characteristics of subjects that participated in Example 4. 4% 8% Placebo RX0041-002 RX0041-002 Overall (N = 95) (N = 275) (N = 278) (N = 648) Characteristic n (%) n (%) n (%) n (%) Age (Yrs) Mean 44.9 45.3 42.7 44.1 SD 16.9 15.3 16.6 16.1 Median 46 45 42 44 Minimum, 18, 80 17, 83 18, 86 17, 86 Maximum Sex Female 55 (57.9%) 167 (60.7%) 170 (61.2%) 392 (60.5%) Male 40 (42.1%) 108 (39.3%) 108 (38.8%) 256 (39.5%) Ethnicity Hispanic or 10 (10.5%) 12 (4.4%) 23 (8.3%) 45 (6.9%) Latino Not Hispanic or 85 (89.5%) 263 (95.6%) 254 (91.4%) 602 (92.9%) Latino Race American Indian 0 (0.0%) 1 (0.4%)  0 (0.0%)  1 (0.2%) or Alaska Asian 1 (1.1%) 3 (1.1%)  1 (0.4%)  5 (0.8%) Black or African 16 (16.8%) 51 (18.5%)  49 (17.6%) 116 (17.9%) American Other 3 (3.2%) 4 (1.5%)  7 (2.5%) 14 (2.2%) White 75 (78.9%) 216 (78.5%)  220 (79.1%) 511 (78.9%) Height (cm) Mean 168.73 168.47 167.89 168.26 SD 9.77 10.56 10.93 10.6 Median 170 168 167.6 168 Minimum, 144.7, 195.5 132.1; 198.1 139.0, 213.3 132.1, 213.3 Maximum Weight (kg) Mean 83.69 83.94 81.57 82.88 SD 22.91 22.99 21.45 22.32 Median 81 80 79.8 80 Minimum, 46.0, 175.0 45.0, 183.3 40.4, 189.0 40.4, 189.0 Maximum. BMI (kg m2) Mean 29.24 29.58 28.92 29.25 SD 6.91 7.79 7.11 7.37 Median 28.40 28.10 27.15 27.80 Minimum, 15.5, 57.0 16.6, 70.1 17.2, 64.5 15.5, 70.1 Maximum

The reasons for the intranasal procedure were well balanced across the placebo, 4% pharmaceutical composition (40 mg/mL cocaine hydrochloride), and 8% pharmaceutical composition (80 mg/mL cocaine hydrochloride) groups (Table 32). The most common diagnostic or surgical procedure in each of the groups was nasal endoscopy (54.7%, 59.6%, and 60.8% in the placebo, 4% pharmaceutical composition, and 8% pharmaceutical composition test groups, respectively).

TABLE 32 Diagnostic or surgical procedures. 4% 8% RX0041- RX0041- Placebo 002 002 Overall (N = 95) (N = 275) (N = 278) (N = 648) Characteristic n (%) n (%) n (%) n (%) Nasal Endoscopy 52 (54.7%) 164 (59.6%)  169 (60.8%) 385 (59.4%) Nasal 14 (14.7%) 33 (12.0%)  43 (15.5%)  90 (13.9%) Laryngoscopy Nasopharyngeal 12 (12.6%) 23 (8.4%)  18 (6.5%) 53 (8.2%) Laryngoscopy Nasal Debridement 3 (3.2%) 19 (6.9%)  15 (5.4%)  37 (5.7%) Nasal Endoscopy 0 (0.0%) 11 (4.0%)  9 (3.2%) 20 (3.1%) with Debridement Intraturbinate 5 (5.3%) 7 (2.5%) 7 (2.5%) 19 (2.9%) DepoMedrol Injection Laryngoscopy 3 (3.2%) 5 (1.8%) 6 (2.2%) 14(2.2%) Turbinate 1 (1.1%) 3 (1.1%) 2 (0.7%) 6 (0.9%) Reduction Transnasal 2 (2.1%) 1 (0.4%) 2 (0.7%) 5 (0.8%) Esophagoscopy Nasal Endoscopy 0 (0.0%) 2 (0.7%) 2 (0.7%) 4 (0.6%) with Polypectomy Sinuplasty 0 (0.0%) 2 (0.7%) 0 (0.0%) 2 (0.3%) Nasal Cauterization 0 (0.0%) 1 (0.4%) 0 (0.0%) 1 (0.2%) Nasal Endoscopy 0 (0.0%) 0 (0.0%) 1 (0.4%) 1 (0.2%) and Nasal Laryngoscopy Nasal Endoscopy 0 (0.0%) 1 (0.4%) 0 (0.0%) 1 (0.2%) and Stroboscopy Nasal Stroboscopy 1 (1.1%) 0 (0.0%) 0 (0.0%) 1 (0.2%)

Efficacy Results

The primary efficacy endpoint, analgesic success in the 4% pharmaceutical composition test group was met (Table 33). A 4% pharmaceutical composition dose significantly increased (81.1%; p<0.0001) the percentage of patients who achieved analgesic success compared with the placebo group (9.5%).

The exploratory efficacy endpoint, analgesic success in the 8% pharmaceutical composition test group, was also met. An 8% pharmaceutical composition dose increased (77.3%; p<0.0001) the percentage of patients who achieved analgesic success compared with the placebo group (9.5%). There was no increase in the percentage of patients who achieved analgesic success when the pharmaceutical composition dose was increased from 4% to 8% (81.1% and 77.3%, respectively).

TABLE 33 Example 4, Analgesic success rates. 4% Anesthetic 8% Anesthetic Placebo composition composition (N = 95) (N = 275) (N = 278) n (%) n (%) n (%) Success 9 (9.5) 223 (81.1)  215 (77.3)  Failure 86 (90.5) 52 (18.9) 63 (22.7) P-value* <0.0001 <0.0001 *Fisher's Exact Test. Pairwise comparison on active drug to placebo.

Within the pharmaceutical composition test groups, the primary reason for analgesic failure was failure to achieve a VNRS of 0 immediately following pharmaceutical composition treatment (51/52 patients and 59/63 patients in the 4% and 8% pharmaceutical composition test groups, respectively) (Table 34).

TABLE 34 Reasons for analgesic failure in the pharmaceutical composition test groups. 4% Anesthetic 8% Anesthetic composition composition (N = 52) (N = 63) VNRS > 0 immediately after study 51 (98.0%) 59 (93.6%) drug treatment Required additional nasal analgesic 1 (2.0%) 4 (6.4%) medication during the procedure VNRS = visual numeric rating scale.

Subgroup Analyses

With the exception of other races (pooled), the significant analgesic success seen with 4% pharmaceutical composition versus placebo in the overall population was maintained for all subgroups (p<0.001), including males and females; whites and blacks; patients ≥44 years and <44 years of age; and patients ≥80 kg and <80 kg (Table 35).

For other races pooled, the analgesic success rate was also higher with 4% pharmaceutical composition (62.5%) compared with placebo (0%), but this difference was not statistically significant (p=0.0808) because of the small number of patients in this subgroup (4 and 5 patients in the placebo and 4% pharmaceutical composition test groups, respectively).

The significant analgesic success seen with 8% pharmaceutical composition versus placebo in the overall population was also maintained for all of the subgroups (p<0.001), with the exception of other races pooled because of the small number of patients in this subgroup (4 and 9 patients in the placebo and 8% pharmaceutical composition test groups, respectively).

TABLE 35 Example 4, analgesic success rates in subgroups 4% Anesthetic 8% Anesthetic Placebo composition composition n/N (%) n/N (%) n/N (%) Sex Males 3/40 (7.5)  89/108 (82.4)^(a)  88/108 (81.5)^(a) Females 6/54 (10.9) 134/167 (81.1)^(a)  127/170 (74.7)^(a) Race White 7/75 (9.3)  175/216 (81.0)^(a)   166/220 (75.5)^(a) Black 2/16 (12.5) 43/51 (84.3)^(a)   40/49 (81.6)^(a) Other races pooled 0/4 (0)     5/8 (62.5)^(b)      9/9 (100.0)^(c) Age ≥44 years 7/53 (13.2) 121/149 (81.2)^(a)    99/134 (73.9)^(a) <44 years 2/42 (4.8)  102/126 (81.0)^(a)   116/144 (80.6)^(a) Weight ≥80 kg 1/49 (2.0)  112/138 (81.2)^(a)   109/138 (79.0)^(a) <80 kg 8/46 (17.4) 110/136 (80.9)^(a)   106/140 (75.7)^(a) ^(a)p < 0.0001. ^(b)p = 0.0808. ^(c)p = 0.0014.

Summary of Example 4 Results

Example 4 was conducted at 9 study sites in 648 patients. The number of patients randomized per study site ranged from 5 to 112, which equates to 0.8% and 17.3% of the patient population, respectively. Thus, Example 4 is a large, multicenter study in which no single study site provided a large fraction of the patients. Example 4 showed consistent analgesic success rates for two doses of pharmaceutical composition versus placebo both in the overall population and across subgroups defined by sex, race, age, and weight. Thus, the efficacy findings for pharmaceutical composition are internally consistent and generalizable.

The p values for the comparison of analgesic success in the 4% pharmaceutical composition versus placebo group were low (p<0.0001 using two-tailed Fisher's exact test at α=0.05). This p value is highly inconsistent with the null hypothesis of no treatment effect for the pharmaceutical composition.

Analysis of Clinical Information Relevant to Dosing Recommendations

Statistically significant and clinically meaningful increases in the percentage of patients who achieved analgesic success (the primary efficacy endpoint) were provided by a topical nasal dose of 4% pharmaceutical composition compared to placebo. Consistent and reproducible results were shown for 4% pharmaceutical composition across all subgroups, including groups defined by sex, race, age, and weight. There was no statistically significant increase in the percentage of patients, either overall or in the subgroups, who achieved analgesic success when the pharmaceutical composition dose was increased to 8%.

Persistence of Efficacy

The pharmaceutical composition provided persistent local nasal anesthesia with no need for additional analgesic medication during diagnostic and surgical procedures on or through the mucous membranes of the nasal cavities. The pharmaceutical composition has a half-life of approximately 1 hour.

Efficacy Conclusions

The pharmaceutical composition is effective for the induction of local anesthesia for diagnostic procedures and surgeries on or through the mucous membranes of the nasal cavities.

The efficacy endpoint in Example 4, analgesic success, was met. Topical nasal doses of 4% pharmaceutical composition (40 mg/mL cocaine hydrochloride) provided statistically significant and clinically meaningful increases in the percentage of patients who achieved analgesic success. Additionally, consistent and reproducible results were shown for the 4% pharmaceutical composition across all subgroups, including groups defined by sex, race, age, and weight.

Example 4 is adequate to support the effectiveness of the pharmaceutical composition because it was a large multi-center study, the efficacy findings in the study are internally consistent and generalizable, and the low p values (p<0.0001) in favor of the pharmaceutical composition for analgesic success are highly inconsistent with the null hypothesis of no treatment effect.

Example 5

Stability studies were conducted on pharmaceutical compositions in a container closure system. The pharmaceutical compositions were aqueous solutions having the composition of the 4% and 8% cocaine hydrochloride solutions described in Example 4. The container closure system used to contain the 4% cocaine hydrochloride pharmaceutical composition consisted of a 0.5 oz. amber glass bottle (depicted in FIGS. 13A and 13B) with a ribbed closure (depicted in FIGS. 14A-14C) containing a foam liner. Aspects of the container closure system are presented in Table 36.

TABLE 36 Container closure system for pharmaceutical composition containing 4% cocaine hydrochloride. Container Closure Manufacturer Bottle: 0.5 oz. Boston round, amber Gerresheimer Essenr glass bottle GmbH Primary Packaging Glass Closure: 18-mm/400 ribbed closure Amcor Rigid Plastics USA, Inc. Liner: F-217 foam Liner Tri-Seal International, Inc.

The amber glass bottle used was a 0.5 oz. boston round, amber glass bottle, made of amber, Type III molded glass. The observed spectral transmission for the glass bottle did not exceed 10% at any wavelength in the range of 290 nm to 450 nm.

The ribbed closure (FIGS. 14A-14C) was made of white polypropylene. The foam liner of was made of three-ply coextruded material including a foamed low density polyethylene core between two solid layers of low density polyethylene. The foam liner was manufactured by Tri-Seal, International, Inc., Blauvel, N.Y., U.S.A.

Three stability studies were conducted on the stability of the 4% cocaine hydrochloride pharmaceutical compositions. The stability studies involved the following testing periods and conditions:

-   -   20 months under long term conditions (25° C.±2° C. and 60%±5%         relative humidity).     -   6 months under accelerated conditions (40° C.±2° C. and 75%±5%         relative humidity).     -   12 months under intermediate conditions (30° C.±2° C. and 65%±5%         relative humidity).

A long-term stability study of the pharmaceutical composition contained in the closure system was conducted over a period of 20 months to determine the rate of physical or chemical degradation of the pharmaceutical composition including 4% cocaine hydrochloride.

All long-term stability samples (each sample containing 4 mL of the pharmaceutical composition including 40 mg/mL cocaine hydrochloride, batch lot S35900113) were placed upright or inverted in an environmental chamber and maintained in an upright or inverted position during the stability study. All of the containers were maintained at 25° C.±2° C. and 60%±5% relative humidity conditions, uninterrupted, (except for the adding or withdrawal of test samples) for a period of twenty months. Samples were removed from conditions at the specified time point and tested for pH, preservative content, related substances, methanol content, microbial limits at the required time point, and cocaine hydrochloride content. Storage of the stability samples was completed using a calibrated environmental chamber. Testing of the stability samples was completed using High Pressure Liquid Chromatography.

Shelf life of the 4% cocaine hydrochloride pharmaceutical composition was estimated to be at least 20 months at ambient conditions, based upon the long term (20 months) stability assay results shown in Table 37 and FIGS. 15 and 16, which are described below. One batch lot of 4% pharmaceutical composition (4 mL containing 40 mg/mL cocaine hydrochloride, batch lot S35900113) was tested in both upright and inverted container orientation over the long term stability conditions of 25±2° C. and 60±5% relative humidity for a period of 20 months. Both assays showed that greater than 90 percent of the cocaine hydrochloride was retained in the pharmaceutical composition over the course of the long term 20 month stability assay.

FIG. 15 is a plot of the percent detectable cocaine hydrochloride versus time for the 4 mL filled upright container of the 4% cocaine hydrochloride pharmaceutical composition (40 mg/mL cocaine hydrochloride), stored under the long term stability conditions of 25±2° C. and 60±5% relative humidity over 20 months.

FIG. 16 is a plot of the percent detectable cocaine hydrochloride versus time for the 4 mL filled inverted container of the 4% cocaine hydrochloride pharmaceutical composition (40 mg/mL cocaine hydrochloride), stored under the long term stability conditions of 25±2° C. and 60±5% relative humidity over 20 months.

Table 37 reports the long-term stability data for the pharmaceutical composition samples tested in Example 5.

TABLE 37 Long-term conditions stability data results for the pharmaceutical composition including 4% cocaine hydrochloride in a 0.5 oz. bottle at 25° C. ± 2° C. and 60% ± 5% relative humidity over a period of 20 months. Time (months) Test Specification Orientation T = 0 T = 6 T = 12 T = 15 T = 18 T = 20 Assay cocaine Upright 100.5% 97.2% 96.9% 94.6% 94.5% 93.3% hydrochloride Inverted 100.5% 97.1% 95.7% 93.1% 92.4% 92.2% Preservative sodium Upright 0.100% 0.103% 0.112% 0.116% 0.118% 0.125% Content benzoate Inverted 0.100% 0.102% 0.109% 0.114% 0.117% 0.124% pH 2.0-4.0 Upright 3.5 3.1 2.9 2.8 2.6 2.7 Inverted 3.5 3.1 2.9 2.8 2.7 2.7 Related benzoyl Upright 0.1% 2.3% 4.3% 5.0% 5.8% 6.5% Substances ecgonine Inverted 0.1% 2.3% 4.3% 4.9% 5.7% 6.4% unspecified Upright <0.1% <0.1% <0.1% <0.1% <0.1% <0.1% impurities Inverted <0.1% <0.1% <0.1% <0.1% <0.1% <0.1% Total Upright 0.1% 2.3% 4.3% 5.0% 5.8% 6.5% Inverted 0.1% 2.3% 4.3% 4.9% 5.7% 6.4% Microbial Total Aerobic Upright conforms N/A conforms conforms conforms conforms Limits Counts Inverted conforms N/A conforms conforms conforms conforms Microbial (NMT 100 cfu/g) Total Combined Upright conforms N/A conforms conforms conforms conforms Mold and Yeast Inverted conforms N/A conforms conforms conforms conforms (NMT 10 cfu/g) Pseudomonas Upright conforms N/A conforms conforms conforms conforms aeruginosa Inverted conforms N/A conforms conforms conforms conforms (Absent) Staphylococcus Upright conforms N/A conforms conforms conforms conforms aureus Inverted conforms N/A conforms conforms conforms conforms (Absent) Methanol Content (ppm) Upright N/A 188 215 245 284 394 Inverted N/A 189 203 238 281 396 N/A—not available

An accelerated stability study of the same manufactured batch lot (batch lot S35900113) pharmaceutical composition as used in the long-term stability study described above (and contained in the closure system) was conducted over a period of 6 months to determine the rate of physical or chemical degradation of the pharmaceutical composition including 4% cocaine hydrochloride over accelerated environmental conditions.

All accelerated stability samples (each sample containing 4 mL of the pharmaceutical composition including 40 mg/mL cocaine hydrochloride) were placed upright or inverted in an environmental chamber and maintained in an upright or inverted position during the stability study. All of the containers were maintained at 40° C.±2° C. and 75%±5% relative humidity, uninterrupted, (except for the adding or withdrawal of test samples) for a period of six months. Samples were removed from conditions at the specified time point and tested for pH, preservative content, related substances, methanol content, microbial limits at the required time point, and cocaine hydrochloride content. Storage of the stability samples was completed using a calibrated environmental chamber. Testing of the stability samples was completed using High Pressure Liquid Chromatography.

Shelf life of the 4% cocaine hydrochloride pharmaceutical composition was estimated at approximately 4 months at the accelerated stability conditions, based upon the short term (4 months) stability assay results shown in Table 38 and FIGS. 17 and 18, which are described below. Both upright and inverted container assays showed greater than 85 percent of the cocaine hydrochloride was retained in the pharmaceutical composition over the course of the accelerated term stability assay for 4 months.

FIG. 17 is a plot of the percent detectable cocaine hydrochloride versus time for the 4 mL filled upright container of the 4% cocaine hydrochloride pharmaceutical composition (40 mg/mL cocaine hydrochloride) over a 6-month period at 40° C.±2° C. and 75%±5% relative humidity, thereby providing an assessment of the shelf life stability of the pharmaceutical composition.

FIG. 18 is a plot of the percent detectable cocaine hydrochloride versus time for the 4 mL filled inverted container of the 4% cocaine hydrochloride pharmaceutical composition (40 mg/mL cocaine hydrochloride) over a 6-month period at 40° C.±2° C. and 75%±5% relative humidity, thereby providing an assessment of the shelf life stability of the pharmaceutical composition.

Table 38 reports the accelerated conditions stability data for the samples tested in Example 5.

TABLE 38 Accelerated conditions stability data results for the pharmaceutical composition including 4% cocaine hydrochloride in a 0.5 oz. bottle at 40 ± 2° C. and 75% ± 5% relative humidity over a period of 4 months. Time (months) Test Specification Orientation T = 0 T = 1 T = 3 T = 4 T = 6 Assay cocaine Upright 100.5% 95.9% 93.3% 92.0% 87.7% hydrochloride Inverted 100.5% 95.9% 94.1% 92.3% 88.1% Preservative sodium Upright 0.100% 0.103% 0.114% 0.120% 0.147% Content benzoate Inverted 0.100% 0.102% 0.114% 0.120% 0.145% pH 2.0-4.0 Upright 3.5 3.2 2.8 2.7 2.5 Inverted 3.5 3.2 2.8 2.7 2.5 Related benzoyl Upright 0.1% 2.0% 4.9% 5.9% 8.8% Substances ecgonine Inverted 0.1% 1.9% 5.0% 5.9% 8.7% unspecified Upright <0.1% <0.1% <0.1% <0.1% <0.1% impurities Inverted <0.1% <0.1% <0.1% <0.1% <0.1% Total Upright 0.1% 2.0% 4.9% 5.9% 8.8% Inverted 0.1% 1.9% 5.0% N/A 8.7% Microbial Total Aerobic Upright conforms N/A N/A N/A conforms Limits Microbial Inverted conforms N/A N/A N/A conforms Counts (NMT 100 fu/g) Total Combined Upright conforms N/A N/A N/A conforms Mold and Yeast Inverted conforms N/A N/A N/A conforms (NMT 10 cfu/g) Pseudomonas Upright conforms N/A N/A N/A conforms aeruginosa Inverted conforms N/A N/A N/A conforms (Absent) Staphylococcus Upright conforms N/A N/A N/A conforms aureus Inverted conforms N/A N/A N/A conforms (Absent) Methanol Content (ppm) Upright N/A N/A N/A <50 114 Inverted N/A N/A N/A <50 111 N/A—not available

An intermediate stability study of the same manufactured batch lot (batch lot S35900113) pharmaceutical composition as used in the long-term and accelerated stability studies described above (and contained in the closure system) was conducted over a period of 12 months to determine the rate of physical or chemical degradation of the pharmaceutical composition including 4% cocaine hydrochloride over intermediate environmental conditions.

All intermediate stability samples (each sample containing 4 mL of the pharmaceutical composition including 40 mg/mL cocaine hydrochloride) were placed upright or inverted in an environmental chamber and maintained in an upright or inverted position during the stability study. All of the containers were maintained at 30° C.±2° C. and 65%±5% relative humidity, uninterrupted, (except for the adding or withdrawal of test samples) for a period of twelve months. Samples were removed from conditions at the specified time point and tested for pH, preservative content, related substances, methanol content, microbial limits at the required time point, and cocaine hydrochloride content. Storage of the stability samples was completed using a calibrated environmental chamber. Testing of the stability samples was completed using High Pressure Liquid Chromatography.

Shelf life of the 4% cocaine hydrochloride pharmaceutical composition was estimated at approximately 12 months at intermediate conditions, based upon the 12-month term stability assay results shown in Table 39 and FIGS. 19 and 20, which are described below. Both upright and inverted container assays show greater than 90 percent of the cocaine hydrochloride was retained in the pharmaceutical composition over the course of the intermediate term stability assay for 12 months.

FIG. 19 is a plot of the percent detectable cocaine hydrochloride versus time for the 4 mL filled upright container of the 4% cocaine hydrochloride pharmaceutical composition (40 mg/mL cocaine hydrochloride) over a 12-month period at 30° C.±2° C. and 65%±5% relative humidity, thereby providing an assessment of the shelf life stability of the pharmaceutical composition.

FIG. 20 is a plot of the percent detectable cocaine hydrochloride versus time for the 4 mL filled inverted container of the 4% cocaine hydrochloride pharmaceutical composition (40 mg/mL cocaine hydrochloride) over a 12-month period at 30° C.±2° C. and 65%±5% relative humidity, thereby providing an assessment of the shelf life stability of the pharmaceutical composition.

Table 39 reports the intermediate conditions stability data for the samples tested in Example 5.

TABLE 39 Intermediate conditions stability data results for the pharmaceutical composition cocaine hydrochloride, 40 mg/mL, in a 0.5 oz. bottle at 30 ± 2° C. and 65 ± 5% relative humidity over a period of 12 months. Time (months) Test Specification Orientation T = 0 T = 3 T = 6 T = 9 T = 12 Assay cocaine Upright 100.5% 96.5% 95.2% 94.2% 91.9% hydrochloride Inverted 100.5% 96.7% 94.1% 94.1% 91.4% Preservative sodium Upright 0.100% 0.104% 0.111% 0.119% 0.129% Content benzoate Inverted 0.100% 0.103% 0.109% 0.118% 0.128% pH 2.0-4.0 Upright 3.5 3.1 2.8 2.6 2.7 Inverted 3.5 3.1 2.8 2.6 2.7 Related benzoyl Upright 0.1% 2.5% 4.1% 5.5% 7.1% Substances ecgonine Inverted 0.1% 2.5% 4.0% 5.5% 7.1% unspecified Upright <0.1% <0.1% <0.1% <0.1% <0.1% impurities Inverted <0.1% <0.1% <0.1% <0.1% <0.1% Total Upright 0.1% 2.5% 4.1% 5.5% 7.1% Inverted 0.1% 2.5% 4.0% 5.5% 7.1% Microbial Total Aerobic Upright conforms N/A N/A N/A conforms Limits Microbial Inverted conforms N/A N/A N/A conforms Counts (NMT 100 cfu/g) Total Combined Upright conforms N/A N/A N/A conforms Mold and Yeast Inverted conforms N/A N/A N/A conforms (NMT 10 cfu/g) Pseudomonas Upright conforms N/A N/A N/A conforms aeruginosa Inverted conforms N/A N/A N/A conforms (Absent) Staphylococcus Upright conforms N/A N/A N/A conforms aureus Inverted conforms N/A N/A N/A conforms (Absent) Methanol Content (ppm) Upright N/A N/A 429 250 343 Inverted N/A N/A 429 251 343 N/A—not available

Stability data for the pharmaceutical composition including cocaine hydrochloride, 80 mg/mL, was completed up to a 12 month time point for long-term stability conditions. Table 40 shows the results of the 12 month long-term conditions stability study.

TABLE 40 Long-term conditions stability data results for the pharmaceutical composition, cocaine hydrochloride, 80 mg/mL, in a 0.5 oz. bottle at 25 ± 2° C. and 60 ± 5% relative humidity over 12 months. Time (month) Test Specification Orientation T = 0 T = 12 Assay cocaine hydrochloride Upright 100.0%  96.1% Inverted 100.0%  96.1% Preservative sodium benzoate Upright 0.100% 0.126% content Inverted 0.100% 0.125% pH 2.0-4.0 Upright 3.5 2.5 Inverted 3.5 2.6 Related Benzoyl Ecgonine Upright/Inverted 0.1%/0.1% 3.7%/3.8% Substances Unspecified impurities Upright/Inverted <0.1%/<0.1% <0.1%/<0.1% Total Upright/Inverted 0.1%/0.1% 3.7%/3.8% Microbial Total Aerobic NMT Upright conforms conforms Limits Microbial 100 cfu/g Inverted conforms conforms Counts Total Combined NMT Upright conforms conforms Mold and Yeast 10 cfu/g Inverted conforms conforms Counts Pseudomonas Absent Upright conforms conforms aeruginosa Inverted conforms conforms Staphylococcus Absent Upright conforms conforms aureus Inverted conforms conforms Methanol Content Upright 22 ppm 366 ppm Inverted 22 ppm 355 ppm NMT—not more than, NLT—not less than, NA—not available

Stability data for 4% cocaine hydrochloride pharmaceutical composition was completed up to the 12 month time point for long-term stability conditions. Table 41 shows the results of the 12 month long-term conditions stability study.

TABLE 41 Long-term conditions stability data results for the pharmaceutical composition, cocaine hydrochloride, 40 mg/mL, (batch lot S35900115) in a 0.5 oz. bottle at 25 ± 2°C. and 60 ± 5% relative humidity over 12 months. Time (month) Test Specification Orientation T = 0 T = 12 Assay cocaine hydrochloride Upright 100.8%  92.7% Inverted 100.8%  93.2% Preservative sodium benzoate Upright 0.099% 0.111% content Inverted 0.099% 0.109% pH 2.0-4.0 Upright 3.6 3.0 Inverted 3.6 3.0 Related Benzoyl Ecgonine Upright/Inverted 0.1%/0.1% 4.3%/4.3% Substances Unspecified impurities Upright/Inverted <0.1%/<0.1% <0.1%/<0.1% Total Upright/Inverted 0.1%/0.1% 4.3%/4.3% Microbial Total Aerobic NMT Upright conforms conforms Limits Microbial 100 cfu/g Inverted conforms conforms Counts Total Combined NMT Upright conforms conforms Mold and Yeast 10 cfu/g Inverted conforms conforms Counts Pseudomonas Absent Upright conforms conforms aeruginosa Inverted conforms conforms Staphylococcus Absent Upright conforms conforms aureus Inverted conforms conforms Methanol Content Upright <37 ppm 189 ppm Inverted <37 ppm 192 ppm NMT—not more than, NLT—not less than, NA—not available

Example 6

A stability study was conducted on 4% and 8% cocaine hydrochloride pharmaceutical compositions as described in Example 4 stored in the container closure system used in Example 5.

Three studies were conducted on the stability of the 4% and 8% cocaine hydrochloride pharmaceutical compositions. The stability studies involved the following compositions, testing periods and conditions:

-   -   4% cocaine hydrochloride, 24 months under refrigerated         conditions (5° C.±2° C.).     -   8% cocaine hydrochloride, 24 months under refrigerated         conditions (5° C.±2° C.).     -   8% cocaine hydrochloride, 21 months under long term conditions         (25° C.±2° C. and 60%±5% relative humidity).

A stability study of the pharmaceutical composition contained in the closure system was conducted over a period of 24 months at refrigerated conditions to determine the rate of physical or chemical degradation of the pharmaceutical composition including 4% cocaine hydrochloride.

All refrigerated stability samples (each sample containing 4 mL of the pharmaceutical composition including 40 mg/mL cocaine hydrochloride, lot C35900114A) were placed upright or inverted in an environmental chamber and maintained in an upright or inverted position during the stability study. All of the containers were maintained at 5° C.±2° C., uninterrupted, (except for the adding or withdrawal of test samples) for a period of twenty four months. Samples were removed from the indicated conditions at the specified time point and tested for pH, preservative content, related substances, methanol content, microbial limits at the required time point, and cocaine hydrochloride content. Storage of the stability samples was completed using a calibrated environmental chamber. Testing of the stability samples was completed using High Pressure Liquid Chromatography.

Shelf life of the 4% cocaine hydrochloride pharmaceutical composition was estimated to be at least 24 months at the refrigerated conditions used, based upon the 24-month term stability assay results shown in Table 42 and FIGS. 21 and 22, which are described below. Both upright and inverted container assays showed that greater than 95 percent of the cocaine hydrochloride was retained in the pharmaceutical composition over the course of the refrigerated stability assay for 24 months.

TABLE 42 Refrigerated conditions stability data results for the pharmaceutical composition including 40 mg/mL cocaine hydrochloride in a 0.5 oz. bottle at 5° C. ± 2° C. over a period of 24 months. (Lot C35900114A) Time (months) Test Specification Orientation T = 0 T = 6 T = 12 T = 18 T = 21 T = 24 Assay cocaine Upright 99.2% 102.4% 99.6% 99.5% 100.1% 99.4% hydrochloride Inverted 99.2% 102.2% 100.9% 99.3% 99.9% 99.6% Preservative sodium Upright 0.100% 0.102% 0.102% 0.102% 0.102% 0.103% Content benzoate Inverted 0.100% 0.101% 0.101% 0.102% 0.101% 0.103% pH 2.0-4.0 Upright 3.5 3.4 3.4 3.4 3.4 3.4 Inverted 3.5 3.4 3.4 3.4 3.4 3.4 Related benzoyl Upright 0.2% 0.4% 0.6% 0.8% 1.0% 1.0% Substances ecgonine Inverted 0.2% 0.4% 0.6% 0.8% 1.0% 1.0% unspecified Upright <0.1% <0.1% <0.1% <0.1% <0.1% <0.1% impurities Inverted <0.1% <0.1% <0.1% <0.1% <0.1% <0.1% Total Upright 0.2% 0.4% 0.6% 0.8% 1.0% 1.0% Inverted 0.2% 0.4% 0.6% 0.8% 1.0% 1.0% Microbial Total Aerobic Upright conforms N/A conforms conforms conforms conforms Limits Microbial Inverted conforms N/A conforms conforms conforms conforms Counts (NMT 100 cfu/g) Total Upright conforms N/A conforms conforms conforms conforms Combined Mold Inverted conforms N/A conforms conforms conforms conforms and Yeast (NMT 10 cfu/g) Pseudomonas Upright conforms N/A conforms conforms conforms conforms aeruginosa Inverted conforms N/A conforms conforms conforms conforms (Absent) Staphylococcus Upright conforms N/A conforms conforms conforms conforms aureus Inverted conforms N/A conforms conforms conforms conforms (Absent) Methanol Content (ppm) Upright 13 <37 <37 38 52 50 Inverted 13 <37 <37 <37 54 49

FIG. 21 is a plot of the percent detectable cocaine hydrochloride versus time for the 4 mL filled upright container of the 4% cocaine hydrochloride pharmaceutical composition (40 mg/mL cocaine hydrochloride, lot C35900114A) over a 24-month period at 5° C.±2° C.

FIG. 22 is a plot of the percent detectable cocaine hydrochloride versus time for the 4 mL filled inverted container of the 4% cocaine hydrochloride pharmaceutical composition (40 mg/mL cocaine hydrochloride, lot C35900114A) over a 24-month period at 5° C.±2° C.

A refrigerated long term stability study of the pharmaceutical composition including 8% cocaine hydrochloride (batch lot S36000214A) contained in the same closure system as used in the stability studies described above was conducted over a period of 24 months to determine the rate of physical or chemical degradation of the pharmaceutical composition when stored under refrigerated environmental conditions.

All refrigerated stability samples (each sample containing 4 mL of the pharmaceutical composition including 80 mg/mL cocaine hydrochloride) were placed upright or inverted in an environmental chamber and maintained in an upright or inverted position during the stability study. All of the containers were maintained at 5° C.±2° C., uninterrupted, (except for the adding or withdrawal of test samples) for a period of twenty four months. Samples were removed from conditions at the specified time point and tested for pH, preservative content, related substances, methanol content, microbial limits at the required time point, and cocaine hydrochloride content. Storage of the stability samples was completed using a calibrated environmental chamber. Testing of the stability samples was completed using High Pressure Liquid Chromatography.

Shelf life of the 8% cocaine hydrochloride pharmaceutical composition was estimated to be at least 24 months at refrigerated conditions, based upon the 24-month term stability assay results shown in Table 43. Both upright and inverted container assays show greater than 95 percent of the cocaine hydrochloride was retained in the pharmaceutical composition over the course of the refrigerated stability assay for 24 months.

TABLE 43 Refrigerated conditions stability data results for the pharmaceutical composition including 80 mg/mL cocaine hydrochloride in a 0.5 oz. bottle at 5° C. ± 2° C. over a period of 24 months. (Lot S36000214A) Time (months) Test Specification Orientation T = 0 T = 6 T = 12 T = 18 T = 21 T = 24 Assay cocaine Upright 102.1% 102.2% 101.1% 100.4% 101.9% 100.5% hydrochloride Inverted 102.1% 102.3% 101.4% 99.6% 102.0% 100.2% Preservative sodium Upright 0.097% 0.099% 0.101% 0.101% 0.103% 0.103% Content benzoate Inverted 0.097% 0.099% 0.100% 0.100% 0.103% 0.103% pH 2.0-4.0 Upright 3.4 3.5 3.4 3.4 3.3 3.3 Inverted 3.4 3.5 3.4 3.4 3.3 3.3 Related benzoyl Upright 0.1% 0.3% 0.5% 0.7% 0.8% 0.9% Substances ecgonine Inverted 0.1% 0.3% 0.5% 0.7% 0.8% 0.9% unspecified Upright <0.1% <0.1% 0.1% @ 0.1% @ <0.1% 0.1% @ impurities RRT RRT RRT 1.16 1.16 1.16 Inverted <0.1% <0.1% 0.1% @ 0.1% @ <0.1% 0.1% @ RRT RRT RRT 1.16 1.16 1.16 Total Upright 0.1% 0.3% 0.6% 0.8% 0.8% 0.9% Inverted 0.1% 0.3% 0.6% 0.7% 0.8% 0.9% Microbial Total Aerobic Upright conforms N/A conforms conforms conforms conforms Limits Microbial Inverted conforms N/A conforms conforms conforms conforms Counts (NMT 100 cfu/g) Total Upright conforms N/A conforms conforms conforms conforms Combined Mold Inverted conforms N/A conforms conforms conforms conforms and Yeast (NMT 10 cfu/g) Pseudomonas Upright conforms N/A conforms conforms conforms conforms aeruginosa Inverted conforms N/A conforms conforms conforms conforms (Absent) Staphylococcus Upright conforms N/A conforms conforms conforms conforms aureus Inverted conforms N/A conforms conforms conforms conforms (Absent) Methanol Content (ppm) Upright 12 37 51 124 82 87 Inverted 12 <37 49 77 82 81

A long term stability study of the pharmaceutical composition (lot S36000214A) contained in the same closure system as used in the stability studies described above was conducted over a period of 21 months to determine the rate of physical or chemical degradation of the pharmaceutical composition including 8% cocaine hydrochloride over long term environmental conditions.

All stability samples (each sample containing 4 mL of the pharmaceutical composition including 80 mg/mL cocaine hydrochloride) were placed upright or inverted in an environmental chamber and maintained in an upright or inverted position during the stability study. All of the containers were maintained at 25° C.±2° C. and 60%±5% relative humidity, uninterrupted, (except for the adding or withdrawal of test samples) for a period of twenty one months. Samples were removed from conditions at the specified time point and tested for pH, preservative content, related substances, methanol content, microbial limits at the required time point, and cocaine hydrochloride content. Storage of the stability samples was completed using a calibrated environmental chamber. Testing of the stability samples was completed using High Pressure Liquid Chromatography.

Shelf life of the 8% cocaine hydrochloride pharmaceutical composition was estimated at approximately 21 months at long term conditions, based upon the 21-month term stability assay results shown in Table 44. Both upright and inverted container assays show greater than 85 percent of the cocaine hydrochloride was retained in the pharmaceutical composition over the course of the long term stability assay for 21 months.

TABLE 44 Long term condition stability data results for the pharmaceutical composition including 80 mg/mL cocaine hydrochloride in a 0.5 oz. bottle at 25° C. ± 2° C. and 60% ± 5% relative humidity over a period of 21 months. (Lot S36000214A) Time (months) Test Specification Orientation T = 0 T = 6 T = 12 T = 15 T = 18 T = 21 Assay cocaine Upright 102.1% 99.5% 96.3% 94.0% 93.5% 93.1% hydrochloride Inverted 102.1% 99.5% 97.2% 94.3% 92.9% 91.9% Preservative sodium Upright 0.097% 0.109% 0.124% 0.135% 0.148% 0.166% Content benzoate Inverted 0.097% 0.107% 0.123% 0.133% 0.146% 0.163% pH 2.0-4.0 Upright 3.4 2.9 2.6 2.5 2.4 2.3 Inverted 3.4 2.9 2.6 2.5 2.4 2.3 Related benzoyl Upright 0.1% 2.1% 3.7% 4.7% 5.6% 6.6% Substances ecgonine Inverted 0.1% 2.0% 3.8% 4.7% 5.5% 6.6% unspecified Upright <0.1% <0.1% 0.1% @ 0.1% @ 0.1% @ <0.1% impurities RRT 1.16 RRT 1.16 RRT 1.16 Inverted <0.1% <0.1% 0.1% @ 0.1% @ 0.1% @ <0.1% RRT 1.16 RRT 1.16 RRT 1.16 Total Upright 0.1% 2.1% 3.8% 4.7% 5.6% 6.6% Inverted 0.1% 2.0% 3.8% 4.7% 5.6% 6.6% Microbial Total Aerobic Upright conforms conforms conforms conforms conforms conforms Limits Microbial Inverted conforms conforms conforms conforms conforms conforms Counts Total Upright conforms conforms conforms conforms conforms conforms Combined Inverted conforms conforms conforms conforms conforms conforms Mold and Yeast Pseudomonas Upright conforms conforms conforms conforms conforms conforms aeruginosa Inverted conforms conforms conforms conforms conforms conforms Staphylococcus Upright conforms conforms conforms conforms conforms conforms aureus Inverted conforms conforms conforms conforms conforms conforms Methanol Content (ppm) Upright 12 185 347 420 442 604 Inverted 12 181 353 430 460 598

It will be understood that the present description illustrates those aspects of the invention relevant to a clear understanding of the invention. Certain aspects that would be apparent to those of ordinary skill in the art and that, therefore, would not facilitate a better understanding of the invention have not been presented in order to simplify the present description. Although only a limited number of embodiments of the present invention are necessarily described herein, one of ordinary skill in the art will, upon considering the foregoing description, recognize that many modifications and variations of the invention may be employed. All such variations and modifications of the invention are intended to be covered by the foregoing description and the following claims.

The following numbered clauses are directed to various non-limiting examples of inventions according to the present disclosure:

-   -   1. A ready to use pharmaceutical composition comprising:         -   about 4% cocaine hydrochloride, by weight; and         -   a preservative in an aqueous solution at a pH of 2 to 4,         -   wherein the cocaine hydrochloride concentration is greater             than about 3.4%, by weight, after the composition has been             stored for 24 months at a temperature ranging from 23° C. to             27° C. and a relative humidity ranging from 55% to 65%.     -   2. The pharmaceutical composition of Clause 1 wherein the         cocaine hydrochloride concentration is greater than about 3.6%,         by weight, after the composition has been stored for 12 months         at a temperature ranging from 23° C. to 27° C. and a relative         humidity ranging from 55% to 65%.     -   3. The pharmaceutical composition of Clause 1, wherein the         preservative comprises sodium benzoate.     -   4. The pharmaceutical composition of Clause 3, wherein the         sodium benzoate concentration in the composition is about 0.1%         by weight.     -   5. The pharmaceutical composition of Clause 3, wherein the         sodium benzoate concentration in the composition ranges from         about 0.07% to about 0.20%, by weight.     -   6. The pharmaceutical composition of Clause 1, further         comprising an acidulant.     -   7. The pharmaceutical composition of Clause 6, wherein the         acidulant comprises citric acid.     -   8. The pharmaceutical composition of Clause 7, wherein the         citric acid concentration in the composition is about 0.125%, by         weight.     -   9. The pharmaceutical composition of Clause 4, further         comprising an acidulant.     -   10. The pharmaceutical composition of Clause 9, wherein the         acidulant comprises citric acid.     -   11. The pharmaceutical composition of Clause 10, wherein the         citric acid concentration in the composition is about 0.125%, by         weight.     -   12. The pharmaceutical composition of Clause 2, wherein the         cocaine hydrochloride concentration is greater than about 3.6%,         by weight, after the composition has been stored for 6 months at         a temperature ranging from 23° C. to 27° C. and a relative         humidity ranging from 55% to 65%.     -   13. The pharmaceutical composition of Clause 2, wherein the         cocaine hydrochloride concentration is greater than about 3.6%,         by weight, after the composition has been stored for 18 months         at a temperature ranging from 23° C. to 27° C. and a relative         humidity ranging from 55% to 65%.     -   14. The pharmaceutical composition of Clause 2, wherein the         cocaine hydrochloride concentration is greater than about 3.6%,         by weight, after the composition has been stored for 20 months         at a temperature ranging from 23° C. to 27° C. and a relative         humidity ranging from 55% to 65%.     -   15. A ready to use pharmaceutical composition comprising:         -   about 4% cocaine hydrochloride, by weight; and         -   a preservative;         -   in an aqueous solution at a pH of 2 to 4,         -   wherein the cocaine hydrochloride concentration is greater             than about 3.4%, by weight, after the composition has been             stored for 6 months at a temperature ranging from 28° C. to             32° C., and a relative humidity ranging from 60% to 70%.     -   16. The pharmaceutical composition of Clause 15, wherein the         cocaine hydrochloride concentration is greater than about 3.6%,         by weight, after the composition has been stored for 6 months at         a temperature ranging from 28° C. to 32° C., and a relative         humidity ranging from 60% to 70%.     -   17. The pharmaceutical composition of Clause 15, wherein the         preservative comprises sodium benzoate.     -   18. The pharmaceutical composition of Clause 17, wherein the         sodium benzoate concentration in the composition is about 0.1%,         by weight.     -   19. The pharmaceutical composition of Clause 17, wherein the         sodium benzoate concentration in the composition ranges from         about 0.07% to about 0.20%, by weight.     -   20. The pharmaceutical composition of Clause 15, further         comprising an acidulant.     -   21. The pharmaceutical composition of Clause 20, wherein the         acidulant comprises citric acid.     -   22. The pharmaceutical composition of Clause 21, wherein the         citric acid concentration in the composition is about 0.125%, by         weight.     -   23. The pharmaceutical composition of Clause 18, further         comprising an acidulant.     -   24. The pharmaceutical composition of Clause 23, wherein the         acidulant comprises citric acid.     -   25. The pharmaceutical composition of Clause 24, wherein the         citric acid concentration in the composition is about 0.125%, by         weight.     -   26. The pharmaceutical composition of Clause 16, wherein the         cocaine hydrochloride concentration is greater than about 3.6%,         by weight, after the composition has been stored for 9 months at         a temperature ranging from 28° C. to 32° C., and a relative         humidity ranging from 60% to 70%.     -   27. The pharmaceutical composition of Clause 16, wherein the         cocaine hydrochloride concentration is greater than about 3.6%,         by weight, after the composition has been stored for 12 months         at a temperature ranging from 28° C. to 32° C., and a relative         humidity ranging from 60% to 70%.     -   28. A ready to use pharmaceutical composition comprising:         -   about 4% cocaine hydrochloride, by weight; and         -   a preservative;         -   in an aqueous solution at a pH of 2 to 4;         -   wherein the cocaine hydrochloride concentration is greater             than about 3.4%, by weight, after the composition has been             stored for 1 month at a temperature ranging from 38° C. to             42° C., and a relative humidity ranging from 70% to 80%.     -   29. The pharmaceutical composition of Clause 28, wherein the         cocaine hydrochloride concentration is greater than about 3.6%,         by weight, after the composition has been stored for 1 month at         a temperature ranging from 38° C. to 42° C., and a relative         humidity ranging from 70% to 80%.     -   30. The pharmaceutical composition of Clause 28, wherein the         preservative comprises sodium benzoate.     -   31. The pharmaceutical composition of Clause 30, wherein the         sodium benzoate concentration in the composition is about 0.1%,         by weight.     -   32. The pharmaceutical composition of Clause 30, wherein the         sodium benzoate concentration in the composition ranges from         about 0.07% to about 0.20%, by weight.     -   33. The pharmaceutical composition of Clause 28, further         comprising an acidulant.     -   34. The pharmaceutical composition of Clause 33, wherein the         acidulant comprises citric acid.     -   35. The pharmaceutical composition of Clause 34, wherein the         citric acid concentration in the composition is about 0.125%, by         weight.     -   36. The pharmaceutical composition of Clause 31, further         comprising an acidulant.     -   37. The pharmaceutical composition of Clause 36, wherein the         acidulant comprises citric acid.     -   38. The pharmaceutical composition of Clause 37, wherein the         citric acid concentration in the composition is about 0.125%, by         weight.     -   39. The pharmaceutical composition of Clause 29, wherein the         cocaine hydrochloride concentration is greater than about 3.6%,         by weight, after the composition has been stored for 3 months at         a temperature ranging from 38° C. to 42° C., and a relative         humidity ranging from 70% to 80% the period of time is at least         3 months.     -   40. The pharmaceutical composition of Clause 29, wherein the         cocaine hydrochloride concentration is greater than about 3.6%,         by weight, after a the composition has been stored for 4 months         at a temperature ranging from 38° C. to 42° C., and a relative         humidity ranging from 70% to 80%     -   41. The pharmaceutical composition of Clause 28, wherein the         cocaine hydrochloride concentration is greater than about 3.4%,         by weight, after a the composition has been stored for 6 months         at a temperature ranging from 38° C. to 42° C., and a relative         humidity ranging from 70% to 80%.     -   42. A storage stable pharmaceutical composition comprising:         -   about 4% cocaine hydrochloride, by weight; and         -   a preservative in an aqueous solution at a pH of 2 to 4,         -   wherein the composition comprises no more than 7% of total             impurities, by weight, after the composition has been stored             for 20 months at a temperature ranging from 23° C. to 27°             C., and a relative humidity ranging from 55% to 65%.     -   43. The composition of Clause 42, wherein the composition         comprises no more than 6.6% benzoylecognine, by weight, after         the composition has been stored for 20 months at a temperature         ranging from 23° C. to 27° C., and a relative humidity ranging         from 55% to 65%.     -   44. A storage stable pharmaceutical composition comprising:         -   about 4% cocaine hydrochloride, by weight; and         -   a preservative in an aqueous solution at a pH of 2 to 4,         -   wherein the composition comprises no more than 8% of total             impurities, by weight, after the composition has been stored             for 12 months at a temperature ranging from 28° C. to 32°             C., and a relative humidity ranging from 60% to 70%.     -   45. The composition of Clause 44, wherein the composition         comprises no more than 7.3% benzoylecognine, by weight, after         the composition has been stored for 20 months at a temperature         ranging from 23° C. to 27° C., and a relative humidity ranging         from 55% to 65%.     -   46. A storage stable pharmaceutical composition comprising:         -   about 4% cocaine hydrochloride, by weight; and         -   a preservative;         -   in an aqueous solution at a pH of 2 to 4;         -   wherein the composition comprises no more than 10% of total             impurities, by weight, after the composition has been stored             for 6 months at a temperature ranging from 38° C. to 42° C.,             and a relative humidity ranging from 70% to 80%.     -   47. The composition of Clause 46, wherein the composition         comprises no more than 5.9% benzoylecognine, by weight, after         the composition has been stored for 4 months at a temperature         ranging from 38° C. to 42° C., and a relative humidity ranging         from 70% to 80%.     -   48. The composition of Clause 46, wherein the composition         comprises no more than 8.8% benzoylecognine, by weight, after         the composition has been stored for 6 months at a temperature         ranging from 38° C. to 42° C., and a relative humidity ranging         from 70% to 80%.     -   49. A pharmaceutical composition for reducing sensation in a         body region of a subject, the pharmaceutical composition         comprising:         -   about 4% cocaine hydrochloride by weight; and         -   a preservative;         -   in an aqueous solution;         -   wherein the pharmaceutical composition provides a cocaine             AUC_(inf) ranging from about 30.8 ng*h/mL to about 79.0             ng*h/mL, following a topical application of the             pharmaceutical composition to the subject for about 20             minutes.     -   50. The pharmaceutical composition of Clause 49, wherein the         preservative comprises sodium benzoate.     -   51. The pharmaceutical composition of Clause 50, wherein sodium         benzoate concentration in the composition is about 0.1%, by         weight.     -   52. The pharmaceutical composition of Clause 50, wherein sodium         benzoate concentration in the composition ranges from about         0.07% to about 0.20%, by weight.     -   53. The pharmaceutical composition of Clause 49, further         comprising an acidulant.     -   54. The pharmaceutical composition of Clause 53, wherein the         acidulant comprises citric acid.     -   55. The pharmaceutical composition of Clause 54, wherein the         citric acid a concentration in the composition is about 0.125%,         by weight.     -   56. The pharmaceutical composition of Clause 51, further         comprising an acidulant.     -   57. The pharmaceutical composition of Clause 56, wherein the         acidulant comprises citric acid.     -   58. The pharmaceutical composition of Clause 57, wherein the         citric acid concentration in the composition is about 0.125%, by         weight.     -   59. A pharmaceutical composition for reducing sensation in a         body region of a subject, the pharmaceutical composition         comprising:         -   about 4% cocaine hydrochloride, by weight; and         -   a preservative;         -   in an aqueous solution, wherein the pharmaceutical             composition provides a cocaine C_(max) ranging from about             19.7 ng/mL to about 54.3 ng/mL following a topical             application of the pharmaceutical composition to the patient             for about 20 minutes.     -   60. The pharmaceutical composition of Clause 59, wherein the         preservative comprises sodium benzoate.     -   61. The pharmaceutical composition of Clause 60, wherein the         sodium benzoate concentration in the composition is about 0.1%,         by weight.     -   62. The pharmaceutical composition of Clause 60, wherein sodium         benzoate concentration in the composition ranges from about         0.07% to about 0.20%, by weight.     -   63. The pharmaceutical composition of Clause 59, further         comprising an acidulant.     -   64. The pharmaceutical composition of Clause 63, wherein the         acidulant comprises citric acid.     -   65. The pharmaceutical composition of Clause 64, wherein the         citric acid concentration in the composition is about 0.125%, by         weight.     -   66. The pharmaceutical composition of Clause 61, further         comprising an acidulant.     -   67. The pharmaceutical composition of Clause 66, wherein the         acidulant comprises citric acid.     -   68. The pharmaceutical composition of Clause 67, wherein the         citric acid concentration in the composition is about 0.125%, by         weight.     -   69. A pharmaceutical composition for reducing sensation in a         body region of a subject, the pharmaceutical composition         comprising:         -   about 4% cocaine hydrochloride, by weight; and         -   a preservative;         -   in an aqueous solution;         -   wherein the pharmaceutical composition provides a cocaine             T_(max) of about 0.09 h to about 0.77 h following a topical             application of the pharmaceutical composition to the patient             for about 20 minutes.     -   70. The pharmaceutical composition of Clause 69, wherein the         preservative comprises sodium benzoate.     -   71. The pharmaceutical composition of Clause 70, wherein the         sodium benzoate concentration in the composition is about 0.1%,         by weight.     -   72. The pharmaceutical composition of Clause 70, wherein sodium         benzoate concentration in the composition ranges from about         0.07% to about 0.20%, by weight.     -   73. The pharmaceutical composition of Clause 69, further         comprising an acidulant.     -   74. The pharmaceutical composition of Clause 73, wherein the         acidulant comprises citric acid.     -   75. The pharmaceutical composition of Clause 74, wherein the         citric acid concentration in the composition is about 0.125%, by         weight.     -   76. The pharmaceutical composition of Clause 71, further         comprising an acidulant.     -   77. The pharmaceutical composition of Clause 76, wherein the         acidulant comprises citric acid.     -   78. The pharmaceutical composition of Clause 77, wherein the         citric acid concentration in the composition is about 0.125%, by         weight.     -   79. A pharmaceutical composition for reducing sensation in a         body region of a patient, the pharmaceutical composition         comprising:         -   about 4% cocaine hydrochloride, by weight; and         -   a preservative, in an aqueous solution,         -   wherein the pharmaceutical composition provides an             absorptivity factor for cocaine in the patient ranging from             about 0.640 h⁻¹ to about 0.687 h⁻¹ following a topical             application of the pharmaceutical composition to the patient             for about 20 minutes.     -   80. The pharmaceutical composition of Clause 79, wherein the         preservative comprises sodium benzoate.     -   81. The pharmaceutical composition of Clause 80, wherein sodium         benzoate concentration in the composition is about 0.1%, by         weight.     -   82. The pharmaceutical composition of Clause 80, wherein sodium         benzoate concentration in the composition ranges from about         0.07% to about 0.20%, by weight.     -   83. The pharmaceutical composition of Clause 79, further         comprising an acidulant.     -   84. The pharmaceutical composition of Clause 83, wherein the         acidulant comprises citric acid.     -   85. The pharmaceutical composition of Clause 84, wherein the         citric acid concentration in the composition is about 0.125%, by         weight.     -   86. The pharmaceutical composition of Clause 81, further         comprising an acidulant.     -   87. The pharmaceutical composition of Clause 86, wherein the         acidulant comprises citric acid.     -   88. The pharmaceutical composition of Clause 87, wherein the         citric acid concentration in the composition is about 0.125%, by         weight.     -   89. The pharmaceutical composition of Clause 88, wherein the         pharmaceutical composition results in a urinary recovery of         cocaine from the patient ranging from about 49.9 μg to about         184.1 μg over a period of 12 hours from the time of         administration.     -   90. A method of administering a topical anesthetic solution to a         patient to reduce sensation in a body region of the patient         comprising:         -   soaking absorbent articles with a cocaine hydrochloride             solution, the cocaine hydrochloride solution including a             concentration of cocaine hydrochloride of about 4%, by             weight; and         -   contacting the absorbent articles with a nasal mucous             membrane of the patient for at least about 20 minutes,         -   wherein the method results in a cocaine AUC_(inf) in the             patient from about 30.8 ng*h/mL to about 79.0 ng*h/mL.     -   91. The method of Clause 90, wherein the cocaine hydrochloride         solution further comprises a preservative and an acidulant.     -   92. The method of Clause 91, wherein the preservative comprises         sodium benzoate in a concentration of about 0.1%, by weight.     -   93. The method of Clause 91, wherein the preservative comprises         sodium benzoate in a concentration ranging from about 0.07% to         about 0.20%, by weight.     -   94. The method of Clause 91, wherein the acidulant comprises         citric acid.     -   95. The method of Clause 94, wherein the acidulant comprises         citric acid in a concentration of about 0.125%, by weight.     -   96. The method of Clause 90, wherein the method further results         in a T_(max) for cocaine in the patient ranging from about 0.09         h to about 0.77 h.     -   97. The method of Clause 90, wherein the method further results         in a C_(max) for cocaine in the patient ranging from about 19.7         ng/mL to about 54.3 ng/mL.     -   98. The method of Clause 95, wherein the method comprises         utilizing four of the absorbent articles, wherein each of the         absorbent articles comprises a cottonoid pledget having         absorbency sufficient to absorb up to about 1 mL of the cocaine         hydrochloride solution.     -   99. The method of Clause 95, further comprising removing the         absorbent articles from contact with the mucous membrane,         wherein following removal of the absorbent articles from contact         with the mucous membrane, each of the absorbent articles retains         at least about 90% of the cocaine hydrochloride originally         absorbed therein.     -   100. A method of administering a topical anesthetic solution to         a patient to reduce sensation in a body region of the patient         comprising:         -   soaking a plurality of absorbent articles with an aqueous             solution comprising about 4%, by weight, cocaine             hydrochloride; and         -   contacting the absorbent articles with a nasal mucous             membrane of the patient for about at least 20 minutes,         -   wherein the method results in a cocaine T_(max) in the             patient ranging from about 0.09 h to about 0.77 h.     -   101. The method of Clause 100 wherein the aqueous solution         further comprises a preservative and an acidulant.     -   102. The method of Clause 101, wherein the preservative         comprises sodium benzoate in a concentration of about 0.1%, by         weight.     -   103. The method of Clause 101, wherein the preservative         comprises sodium benzoate in a concentration ranging from about         0.07% to about 0.20%, by weight.     -   104. The method of Clause 101, wherein the acidulant comprises         citric acid.     -   105. The method of Clause 104, wherein the acidulant comprises         citric acid in a concentration of about 0.125%, by weight.     -   106. A method of administering a topical anesthetic solution to         a patient to provide a reduction in sensation in a body region         of the patient comprising:         -   soaking a plurality of absorbent articles with an aqueous             solution comprising about 4% cocaine hydrochloride, by             weight; and         -   contacting the absorbent articles with a nasal mucous             membrane of the patient for at least about 20 minutes,             wherein the method achieves a cocaine C_(max) in the patient             ranging from about 19.7 ng/mL to about 54.3 ng/mL.     -   107. The method of Clause 106, wherein the aqueous solution         further comprises a preservative and an acidulant.     -   108. The method of Clause 107, wherein the preservative         comprises sodium benzoate in a concentration of about 0.1%, by         weight.     -   109. The method of Clause 107, wherein the preservative         comprises sodium benzoate in a concentration ranging from about         0.07% to about 0.20%, by weight.     -   110. The method of Clause 107, wherein the acidulant comprises         citric acid.     -   111. The method of Clause 110, wherein the acidulant comprises         citric acid in a concentration of about 0.125%, by weight.     -   112. A method of administering a topical localized anesthetic         composition to a patient comprising:         -   soaking a plurality of absorbent articles with an aqueous             solution comprising about 4% cocaine hydrochloride, by             weight; and         -   contacting the absorbent articles with a nasal mucous             membrane of the patient for at least about 20 minutes,         -   wherein the method results in an absorptivity factor for             cocaine in the patient ranging from about 0.640 h⁻¹ to about             0.687 h⁻¹.     -   113. The method of Clause 112, wherein the aqueous solution         further comprises a preservative and an acidulant.     -   114. The method of Clause 113, wherein the preservative         comprises sodium benzoate in a concentration of about 0.1%, by         weight.     -   115. The method of Clause 113, wherein the preservative         comprises sodium benzoate in a concentration ranging from about         0.07% to about 0.20%, by weight.     -   116. The method of Clause 113, wherein the acidulant comprises         citric acid.     -   117. The method of Clause 116, wherein the acidulant comprises         citric acid in a concentration of about 0.125%, by weight.     -   118. A method of administering a topical localized anesthetic         composition to a patient comprising:         -   soaking a plurality of absorbent articles with an aqueous             solution comprising 4% cocaine hydrochloride, by weight; and         -   contacting the absorbent articles with a nasal mucous             membrane of the patient for about 20 minutes;         -   wherein a urinary recovery of cocaine hydrochloride in the             patient ranges from about 38.9 μg to about 289.5 μg over a             period of 32 hours from the time of administration.     -   119. The method of Clause 118, wherein the aqueous solution         further comprises a preservative and an acidulant.     -   120. The method of Clause 119, wherein the preservative         comprises sodium benzoate in a concentration of about 0.1%, by         weight.     -   121. The method of Clause 119, wherein the preservative         comprises sodium benzoate in a concentration ranging from about         0.07% to about 0.20%, by weight.     -   122. The method of Clause 119, wherein the acidulant comprises         citric acid.     -   123. The method of Clause 122, wherein the acidulant comprises         citric acid in a concentration of about 0.125%, by weight.     -   124. The method of Clause 118, wherein the renal clearance of         cocaine from the patient ranges from about 0.61 L/h to about         3.39 L/h over a period of 32 hours from the time of         administration.     -   125. The method of Clause 118, wherein a urinary recovery of         ecgonine methyl ester from the patient ranges from about 321.5         μg to about 1868.5 μg over a period of 32 hours from the time of         administration.     -   126. The method of Clause 118, wherein a urinary recovery of         benzoylecgonine from the patient ranges from about 469 μg to         about 5059 μg over a period of 32 hours from the time of         administration.     -   127. A method of administering a topical anesthetic solution to         a patient to reduce sensation in a body region of the patient         comprising:         -   soaking a plurality of absorbent articles with an anesthetic             solution including about 4%, by weight, cocaine             hydrochloride; and         -   contacting the absorbent articles with a nasal mucous             membrane of the patient for at least about 20 minutes,         -   wherein the method results in an ecgonine methyl ester             C_(max) in the patient ranging from about 1.8 ng/mL to about             13.2 ng/mL.     -   128. The method of Clause 127, further comprising administering         a second anesthetic to the patient if the ecgonine methyl ester         C_(max) is less than about 1.8 ng/mL.     -   129. A method of administering a topical anesthetic solution to         a patient to reduce sensation in a body region of the patient         comprising:         -   soaking a plurality of absorbent articles with an anesthetic             solution including about 4%, by weight, cocaine             hydrochloride; and         -   contacting the absorbent articles with a nasal mucous             membrane of the patient for at least about 20 minutes,         -   wherein the method results in a benzoylecgonine C_(max) in             the patient ranging from about 8.4 ng/mL to about 103 ng/mL.     -   130. The method of Clause 129, further comprising administering         a second anesthetic to the patient if the benzoylecgonine         C_(max) is less than about 8.4 ng/mL.     -   131. A method for induction of local anesthesia prior to         performing a diagnostic procedure on, through, or adjacent the         mucous membrane of the nasal cavities of a patient comprising:         -   soaking a cottonoid pledget with about 1 mL of an aqueous             solution comprising, by weight:             -   about 4% cocaine hydrochloride;             -   about 0.1% sodium benzoate;             -   about 0.125% citric acid;             -   optionally, at least one coloring additive; and             -   water and         -   contacting the soaked cottonoid pledget with the mucous             membrane of the patient for at least about 20 minutes to             reduce sensation in a body region of the patient.     -   132. The method of Clause 131, wherein the diagnostic procedure         comprises nasal endoscopy.     -   133. The method of Clause 132, wherein the diagnostic procedure         comprises nasal endoscopy with debridement.     -   134. The method of Clause 131, wherein the diagnostic procedure         comprises laryngoscopy.     -   135. The method of Clause 134, wherein the diagnostic procedure         comprises nasal laryngoscopy.     -   136. The method of Clause 134, wherein the diagnostic procedure         comprises nasopharyngeal laryngoscopy.     -   137. The method of Clause 131, wherein the diagnostic procedure         comprises transnasal esophagoscopy.     -   138. The method of Clause 131, wherein the diagnostic procedure         comprises nasal stroboscopy.     -   139. A method for inducing local anesthesia prior to performing         a post-operative procedure on, through, or adjacent the mucous         membrane of the nasal cavities of a patient comprising:         -   soaking a cottonoid pledget with about 1 mL of a colored             aqueous solution comprising, by weight:             -   about 4% cocaine hydrochloride;             -   about 0.1% sodium benzoate and             -   about 0.125% citric acid;             -   optionally, at least one coloring additive; and             -   water and         -   contacting the soaked cottonoid pledget with the mucous             membrane of the patient for about at least 20 minutes to             reduce sensation in a body region.     -   140. The method of Clause 139, wherein the post-operative         procedure comprises nasal debridement.     -   141. A method for inducing local anesthesia prior to performing         a surgical procedure on, through, or adjacent the mucous         membrane of the nasal cavities of a patient comprising:         -   soaking a cottonoid pledget with about 1 mL of an aqueous             solution comprising, by weight:             -   about 4% cocaine hydrochloride;             -   about 0.1% sodium benzoate;             -   about 0.125% citric acid;             -   optionally, at least one coloring additive; and             -   water; and         -   contacting the soaked cottonoid pledget with the mucous             membrane of the patient for at least about 20 minutes to             reduce sensation in a body region.     -   142. The method of Clause 141, wherein the surgical procedure         comprises intraturbinate methylprednisolone acetate injection.     -   143. The method of Clause 141, wherein the surgical procedure         comprises turbinate reduction.     -   144. The method of Clause 141, wherein the surgical procedure         comprises sinuplasty.     -   145. The method of Clause 141, wherein the surgical procedure         comprises at least one of nasal cauterization, nasal endoscopy         with debridement, or nasal endoscopy with polypectomy.     -   146. A method of effectively anesthetizing a body region of a         patient comprising:         -   immersing at least one absorbent article in an aqueous             pharmaceutical composition comprising, by weight:             -   about 3.6% to about 4.4% cocaine hydrochloride;             -   about 0.07% to about 0.20% sodium benzoate; and             -   about 0.125% citric acid;             -   wherein the aqueous pharmaceutical composition has a pH                 between 2 and 4; and         -   contacting the absorbent article and the aqueous             pharmaceutical composition absorbed therein with a mucous             membrane of the patient for a time period;         -   thereby obtaining a visual numeric rating score of 0 in the             body region proximate to the mucous membrane upon von Frey             filament testing.     -   147. The method of Clause 146, wherein the absorbent article         comprises a cottonoid pledget.     -   148. The method of Clause 147, wherein the cottonoid pledget         exhibits dimensions of 1.3 cm by 4 cm and absorbency sufficient         to absorb up to about 1 mL of the aqueous pharmaceutical         composition.     -   149. The method of Clause 148, further comprising removing the         cottonoid pledget from contact with the mucous membrane, wherein         following removal, the absorbent article retains at least 90% of         the cocaine hydrochloride originally absorbed therein.     -   150. A method of effectively anesthetizing a body region of a         patient prior to performing a medical procedure on the patient         comprising:         -   immersing at least one absorbent article in an aqueous             pharmaceutical composition comprising, by weight:             -   about 3.6% to about 4.4% cocaine hydrochloride;             -   about 0.07% to about 0.20% sodium benzoate; and             -   about 0.125% citric acid;             -   wherein the aqueous pharmaceutical composition has a pH                 between 2 and 4; and         -   contacting the absorbent article and the aqueous             pharmaceutical composition absorbed therein with a mucous             membrane of the patient for a time period sufficient to             result in a visual numeric rating score of 0 in the body             region proximate to the mucous membrane upon von Frey             filament testing.     -   151. The method of Clause 150, wherein the medical procedure is         at least one procedure selected from the group consisting of         nasal endoscopy, laryngoscopy, nasopharyngeal laryngoscopy,         nasal laryngoscopy, nasal debridement, intraturbinate         methylprednisolone acetate injection, turbinate reduction,         transnasal esophagoscopy, sinuplasty, nasal cauterization,         stroboscopy, nasal stroboscopy, and polypectomy.     -   152. A method of effectively anesthetizing a body region of a         hepatically impaired patient comprising:         -   immersing at least one absorbent article in an aqueous             pharmaceutical composition comprising, by weight:             -   about 3.6% to about 4.4% cocaine hydrochloride;             -   about 0.07% to about 0.20% sodium benzoate; and             -   about 0.125% citric acid;             -   wherein the aqueous pharmaceutical composition has a pH                 between 2 and 4; and         -   contacting the absorbent article and the aqueous             pharmaceutical composition absorbed therein with a mucous             membrane of the patient for a time period sufficient to             result in a visual numeric rating score of 0 in the body             region proximate to the mucous membrane upon von Frey             filament testing, wherein contacting an absorbent article             containing the aqueous pharmaceutical composition with the             mucous membrane is not repeated within 24 hours.     -   153. The method of Clause 152, wherein a plasma concentration of         cocaine in the patient exhibits a C_(max) ranging from about         16.2 ng/mL to about 85.2 ng/mL.     -   154. The method of Clause 152, wherein a T_(max) value for         cocaine observed in the patient ranges from about 0.306 h to         about 1.874 h.     -   155. The method of Clause 152, wherein plasma cocaine in the         patient exhibits an AUC_(inf) ranging from about 88.0 ng*h/mL to         about 366 ng*h/mL.     -   156. The method of Clause 152, wherein a CL/F of cocaine in the         patient ranges from about 390 L/h to about 1344 L/h.     -   157. The method of Clause 152, wherein a urinary recovery of         cocaine hydrochloride from the patient ranges from about 18.3 μg         to about 389.7 μg over a period of 32 hours from the time of the         administration.     -   158. The method of Clause 152, wherein a renal clearance for         cocaine in the patient ranges from about 0.076 L/h to about         1.918 L/h over a period of 32 hours from the time of the         administration.     -   159. The method of Clause 152, wherein an absorptivity factor         for cocaine in the patient ranges from about 0.184 h⁻¹ to about         0.233 h⁻¹.     -   160. A method of effectively anesthetizing a body region of a         renally impaired patient comprising:         -   immersing at least one absorbent article in an aqueous             pharmaceutical composition comprising, by weight:             -   about 3.6% to about 4.4% cocaine hydrochloride;             -   about 0.07% to about 0.20% sodium benzoate; and             -   about 0.125% citric acid;         -   wherein the aqueous pharmaceutical composition has a pH             between 2 and 4; and contacting the absorbent article and             the aqueous pharmaceutical composition absorbed therein with             a mucous membrane of the patient for a time period             sufficient to result in a visual numeric rating score of 0             in the body region proximate to the mucous membrane upon von             Frey filament testing.     -   161. The method of Clause 160, wherein a plasma concentration of         cocaine in the patient exhibits a C_(max) ranging from about         21.9 ng/mL to about 93.7 ng/mL.     -   162. The method of Clause 160, wherein a T_(max) value observed         in the patient ranges from about 0.301 h to about 0.595 h.     -   163. The method of Clause 160, wherein the AUC for cocaine in         the patient ranges from about 61.2 ng*h/mL to about 179.6         ng*h/mL.     -   164. The method of Clause 160, wherein a CL/F of cocaine from         the patient ranges from about 645 L/h to about 2389 L/h.     -   165. The method of Clause 160, wherein a urinary recovery of         cocaine from the patient ranges from about 7.1 μg to about 269.9         μg over a period of 32 hours from the time of administration.     -   166. The method of Clause 160, wherein a renal clearance for         cocaine in the patient ranges from about 0.528 L/h to about         1.912 L/h over a period of 32 hours from the time of         administration.     -   167. The method of Clause 160, wherein an absorptivity factor         for cocaine in the patient ranges from about 0.358 h⁻¹ to about         0.522 h⁻¹.     -   168. The method of Clause 160, further comprising administering         a second anesthetic composition to the patient if the Cm of         ecgonine methyl ester in the patient falls outside the range of         about 6.0 ng/mL to about 17.8 ng/mL.     -   169. The method of Clause 160, further comprising administering         a second anesthetic composition to the patient if the C_(max) of         benzoylecgonine in the patient falls outside the range of about         21.3 ng/mL to about 219.5 ng/mL.     -   170. A ready to use pharmaceutical composition comprising:         -   about 4% cocaine hydrochloride, by weight; and         -   a preservative in an aqueous solution at a pH of 2 to 4,         -   wherein the cocaine hydrochloride concentration is greater             than about 3.4%, by weight, after the composition has been             stored for 24 months at a temperature ranging from 3° C. to             7° C.     -   171. The pharmaceutical composition of Clause 170 wherein the         cocaine hydrochloride concentration is greater than about 3.6%,         by weight, after the composition has been stored for 21 months         at a temperature ranging from 3° C. to 7° C.     -   172. The pharmaceutical composition of Clause 170, wherein the         preservative comprises sodium benzoate.     -   173. The pharmaceutical composition of Clause 172, wherein the         sodium benzoate concentration in the composition is about 0.1%         by weight.     -   174. The pharmaceutical composition of Clause 172, wherein the         sodium benzoate concentration in the composition ranges from         about 0.07% to about 0.20%, by weight.     -   175. The pharmaceutical composition of Clause 170, further         comprising an acidulant.     -   176. The pharmaceutical composition of Clause 175, wherein the         acidulant comprises citric acid.     -   177. The pharmaceutical composition of Clause 176, wherein the         citric acid concentration in the composition is about 0.125%, by         weight.     -   178. The pharmaceutical composition of Clause 173, further         comprising an acidulant.     -   179. The pharmaceutical composition of Clause 178, wherein the         acidulant comprises citric acid.     -   180. The pharmaceutical composition of Clause 179, wherein the         citric acid concentration in the composition is about 0.125%, by         weight.     -   181. The pharmaceutical composition of Clause 171, wherein the         cocaine hydrochloride concentration is greater than about 3.6%,         by weight, after the composition has been stored for 18 months         at a temperature ranging from 3° C. to 7° C.     -   182. The pharmaceutical composition of Clause 171, wherein the         cocaine hydrochloride concentration is greater than about 3.6%,         by weight, after the composition has been stored for 12 months         at a temperature ranging from 3° C. to 7° C.     -   183. A ready to use pharmaceutical composition comprising:         -   about 8% cocaine hydrochloride, by weight; and         -   a preservative;         -   in an aqueous solution at a pH of 2 to 4;         -   wherein the cocaine hydrochloride concentration is greater             than about 3.4%, by weight, after the composition has been             stored for 24 months at a temperature ranging from 3° C. to             7° C.     -   184. The pharmaceutical composition of Clause 183, wherein the         cocaine hydrochloride concentration is greater than about 3.6%,         by weight, after the composition has been stored for 21 months         at a temperature ranging from 3° C. to 7° C.     -   185. The pharmaceutical composition of Clause 183, wherein the         preservative comprises sodium benzoate.     -   186. The pharmaceutical composition of Clause 185, wherein the         sodium benzoate concentration in the composition is about 0.1%,         by weight.     -   187. The pharmaceutical composition of Clause 185, wherein the         sodium benzoate concentration in the composition ranges from         about 0.07% to about 0.20%, by weight.     -   188. The pharmaceutical composition of Clause 183, further         comprising an acidulant.     -   189. The pharmaceutical composition of Clause 188, wherein the         acidulant comprises citric acid.     -   190. The pharmaceutical composition of Clause 189, wherein the         citric acid concentration in the composition is about 0.125%, by         weight.     -   191. The pharmaceutical composition of Clause 186, further         comprising an acidulant.     -   192. The pharmaceutical composition of Clause 191, wherein the         acidulant comprises citric acid.     -   193. The pharmaceutical composition of Clause 192, wherein the         citric acid concentration in the composition is about 0.125%, by         weight.     -   194. The pharmaceutical composition of Clause 184, wherein the         cocaine hydrochloride concentration is greater than about 3.6%,         by weight, after the composition has been stored for 18 months         at a temperature ranging from 3° C. to 7° C.     -   195. The pharmaceutical composition of Clause 184, wherein the         cocaine hydrochloride concentration is greater than about 3.6%,         by weight, after a the composition has been stored for 12 months         at a temperature ranging from 3° C. to 7° C.     -   196. The pharmaceutical composition of Clause 183, wherein the         cocaine hydrochloride concentration is greater than about 3.6%,         by weight, after a the composition has been stored for 6 months         at a temperature ranging from 3° C. to 7° C.     -   197. A storage stable pharmaceutical composition comprising:         -   about 8% cocaine hydrochloride, by weight; and         -   a preservative in an aqueous solution at a pH of 2 to 4,         -   wherein the composition comprises no more than 4% of total             impurities, by weight, after the composition has been stored             for 24 months at a temperature ranging from 23° C. to 27°             C., and a relative humidity ranging from 55% to 65%.     -   198. The composition of Clause 197, wherein the composition         comprises no more than 2.0% benzoylecognine, by weight, after         the composition has been stored for 21 months at a temperature         ranging from 23° C. to 27° C., and a relative humidity ranging         from 55% to 65%.     -   199. A storage stable pharmaceutical composition comprising:         -   about 4% cocaine hydrochloride, by weight; and         -   a preservative in an aqueous solution at a pH of 2 to 4,         -   wherein the composition comprises no more than 3% of total             impurities, by weight, after the composition has been stored             for 24 months at a temperature ranging from 3° C. to 7° C.     -   200. The composition of Clause 199, wherein the composition         comprises no more than 3.0% benzoylecognine, by weight, after         the composition has been stored for 24 months at a temperature         ranging from 3° C. to 7° C.     -   201. The composition of Clause 199, wherein the composition         comprises no more than 1.5% benzoylecognine, by weight, after         the composition has been stored for 12 months at a temperature         ranging from 3° C. to 7° C.     -   202. The composition of Clause 199, wherein the composition         comprises no more than 1.5% benzoylecognine, by weight, after         the composition has been stored for 4 months at a temperature         ranging from 3° C. to 7° C.     -   203. A storage stable pharmaceutical composition comprising:         -   about 4% cocaine hydrochloride, by weight; and         -   a preservative;         -   in an aqueous solution at a pH of 2 to 4;         -   wherein the composition comprises no more than 3% of total             impurities, by weight, after the composition has been stored             for 6 months at a temperature ranging from 23° C. to 27° C.,             and a relative humidity ranging from 55% to 65%. 

What is claimed is:
 1. A method of administering a local anesthetic prior to performing a diagnostic or surgical procedure on a renally impaired subject comprising: soaking one or more pledgets in up to about 4 mL of a ready-to-use composition comprising about 3.6% to about 4.4% cocaine hydrochloride, by weight, a preservative, an acidulant, and optionally, at least one coloring additive; contacting each pledget on a nasal mucous membrane of the subject up to about 20 minutes; and removing each pledget from contact with a mucous membrane.
 2. The method of claim 1, wherein, the renally impaired subject has an estimated glomerular filtration rate (eGFR) in the range of about 15 mL/min./1.73 m² to less than 60 mL/min./1.73 m².
 3. The method of claim 1, wherein, the renally impaired subject has an estimated glomerular filtration rate (eGFR) in the range of about 15 mL/min./1.73 m² to less than about 29 mL/min./1.73 m².
 4. The method of claim 1, wherein the procedure comprises nasal endoscopy.
 5. The method of claim 1, wherein the procedure comprises nasal laryngoscopy.
 6. The method of claim 1, wherein the procedure comprises nasal debridement.
 7. The method of claim 1, wherein the procedure comprises nasopharyngeal laryngoscopy.
 8. The method of claim 1, wherein the procedure comprises laryngoscopy.
 9. The method of claim 1, wherein the method achieves an absorptivity factor for cocaine in the subject in the range of 0.640 h⁻¹ to 0.687 h⁻¹.
 10. The method of claim 1, wherein the method achieves an absorptivity factor for cocaine in the subject in the range of 0.483 h⁻¹ to 0.789 h⁻¹. 